Provider Demographics
NPI:1497857494
Name:MATTINGLY, JASON E (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:E
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6218
Mailing Address - Country:US
Mailing Address - Phone:502-588-9494
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-634-6767
Practice Address - Fax:502-634-6775
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34956207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000786858OtherANTHEM BC/BS
IN200266300Medicaid
KY50042930OtherPASSPORT
KY34956OtherKY MEDICAID
KY64004922Medicaid
IN200266300Medicaid
H11219Medicare UPIN
KYK056270Medicare PIN