Healthcare Provider Details

I. General information

NPI: 1659549681
Provider Name (Legal Business Name): MICHAEL C MATTINGLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 LIBERTY RD
FLOWOOD MS
39232-9000
US

IV. Provider business mailing address

803 LIBERTY RD
FLOWOOD MS
39232-9000
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-1967
  • Fax: 601-714-1966
Mailing address:
  • Phone: 601-714-1967
  • Fax: 601-714-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26254
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number26254
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: