Provider Demographics
NPI:1851442180
Name:MATTINGLY, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:G4007 W COURT ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3560
Mailing Address - Country:US
Mailing Address - Phone:810-732-0908
Mailing Address - Fax:810-732-1630
Practice Address - Street 1:G4007 W COURT ST
Practice Address - Street 2:SUITE E
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3560
Practice Address - Country:US
Practice Address - Phone:810-732-0908
Practice Address - Fax:810-732-1630
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301068512208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4590228OtherMEDICAID
MIBLUE CROSS COMMUNITYOtherBLUE CROSS COMMUNITY BLUE
MI7676408OtherAETNA
MIBLUE CROSS BLUE SHIEOtherBLUE SHIELD BLUE SHIELD
MI11500OtherMCARE
MI0N53520OtherMEDICARE
MI11500OtherMCARE
H67927Medicare UPIN