Provider Demographics
NPI:1265849053
Name:MATTINGLY, THERESA KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KATHERINE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 NE RALPH POWELL RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2301
Mailing Address - Country:US
Mailing Address - Phone:816-524-4747
Mailing Address - Fax:
Practice Address - Street 1:3265 NE RALPH POWELL RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2301
Practice Address - Country:US
Practice Address - Phone:816-524-4747
Practice Address - Fax:816-524-4929
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125064953207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology