Provider Demographics
NPI:1043298292
Name:MATTINGLY, THOMAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2060
Mailing Address - Country:US
Mailing Address - Phone:765-423-2977
Mailing Address - Fax:765-423-1149
Practice Address - Street 1:1410 UNION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2060
Practice Address - Country:US
Practice Address - Phone:765-423-2977
Practice Address - Fax:765-423-1149
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-07
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026310A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351654025OtherBANKERS LIFE
INB29527OtherADVANTAGE HEALTH SOLUTION
IN351654025OtherUNITED HEALTH CARE
IN000000086144OtherANTHEM INSURANCE
IN351654025OtherPACIFICARE
IN35-1654025OtherAETNA
IN351654025 47904 002OtherTRICARE
IN351654025OtherUNICARE
INB29527OtherADVANTAGE HEALTH SOLUTION
IN180003762Medicare PIN