Healthcare Provider Details

I. General information

NPI: 1710482336
Provider Name (Legal Business Name): TYLER MATTINGLY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463386 STATE ROAD 200 UNIT A
YULEE FL
32097-3240
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-406-3888
  • Fax:
Mailing address:
  • Phone: 904-282-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS20033
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: