Provider Demographics
NPI:1568453546
Name:MATTINGLY, CHRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
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 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4028
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:155 CRYSTAL RUN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4028
Practice Address - Country:US
Practice Address - Phone:845-703-6999
Practice Address - Fax:845-703-6297
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2547772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03244337Medicaid
NY03244337Medicaid
NYA400044781Medicare PIN
OK23366OtherOK STATE MEDICAL LICENSE
249329404Medicare ID - Type Unspecified
NYA400048348Medicare PIN
H94969Medicare UPIN
NY03244337Medicaid