Provider Demographics
NPI:1215933379
Name:MATTINGLY, GREGORY WARREN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WARREN
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 1:4801 WELDON SPRING PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-9101
Mailing Address - Country:US
Mailing Address - Phone:636-949-5760
Mailing Address - Fax:636-949-0729
Practice Address - Street 1:330 1ST CAPITOL DR
Practice Address - Street 2:STE 390
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2852
Practice Address - Country:US
Practice Address - Phone:636-949-5760
Practice Address - Fax:636-949-0729
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1029642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
17646OtherBLUE CROSS BLUE SHIELD
212683OtherHEALTHLINK
212683OtherHEALTHLINK
001011899Medicare ID - Type Unspecified