Provider Demographics
NPI:1508048257
Name:MATTINGLY, DUSTAN J (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTAN
Middle Name:J
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5217
Mailing Address - Country:US
Mailing Address - Phone:314-635-1008
Mailing Address - Fax:314-635-1013
Practice Address - Street 1:8430 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5217
Practice Address - Country:US
Practice Address - Phone:314-635-1008
Practice Address - Fax:314-635-1013
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002102111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508048257OtherNPI
MO371318656OtherEIN
MO000025565Medicare PIN