Provider Demographics
NPI:1952355786
Name:MATTINGLY, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2202
Mailing Address - Country:US
Mailing Address - Phone:618-304-8392
Mailing Address - Fax:443-451-8601
Practice Address - Street 1:12 WOLF CREEK DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2314
Practice Address - Country:US
Practice Address - Phone:618-277-7912
Practice Address - Fax:618-277-7915
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00360968432085R0202X
MO1033792085R0202X, 2085N0700X
IL0360968432085N0700X
KY426282085R0202X, 2085N0700X
IN01066438A2085R0202X, 2085N0700X
MDD00683412085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01026934OtherRR MEDICARE
IL366096843Medicaid
IL0360916843Medicaid
376069OtherHEALTHLINK
IL366096843Medicaid
376069OtherHEALTHLINK
ILIL5602006Medicare PIN
P01026934OtherRR MEDICARE