Provider Demographics
NPI:1558363366
Name:MATTINGLY, SALLY S (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:S
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SALLY
Other - Middle Name:S
Other - Last Name:SHERARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8 N HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3671
Mailing Address - Country:US
Mailing Address - Phone:715-848-0196
Mailing Address - Fax:
Practice Address - Street 1:2400 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-7803
Practice Address - Country:US
Practice Address - Phone:715-847-2022
Practice Address - Fax:715-847-2775
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28953208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30859700Medicaid
WIB54884Medicare UPIN