Provider Demographics
NPI:1235102674
Name:METTETAL, CARY NOLAN (DO)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:NOLAN
Last Name:METTETAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E LEE ST
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-1227
Mailing Address - Country:US
Mailing Address - Phone:662-487-0004
Mailing Address - Fax:662-487-0006
Practice Address - Street 1:401 E LEE ST
Practice Address - Street 2:
Practice Address - City:SARDIS
Practice Address - State:MS
Practice Address - Zip Code:38666-1227
Practice Address - Country:US
Practice Address - Phone:662-487-0004
Practice Address - Fax:662-487-0006
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120459Medicaid
MS00120459Medicaid
MS010000421Medicare ID - Type Unspecified