Provider Demographics
NPI:1104186907
Name:MATTINGLY, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:20291 SUMMERLIN RD STE 105
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3759
Practice Address - Country:US
Practice Address - Phone:239-387-1540
Practice Address - Fax:239-387-1541
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2023-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME146476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200444630AMedicaid
OK430265YRHZOtherMEDICARE GROUP PTAN