Healthcare Provider Details

I. General information

NPI: 1255697975
Provider Name (Legal Business Name): JAMESON KYLE MATTINGLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 12/09/2023
Certification Date: 12/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 PARK WEST BLVD STE 330
KNOXVILLE TN
37923-4203
US

IV. Provider business mailing address

9430 PARK WEST BLVD STE 330
KNOXVILLE TN
37923-4203
US

V. Phone/Fax

Practice location:
  • Phone: 865-693-6065
  • Fax: 865-531-6325
Mailing address:
  • Phone: 865-693-6065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number62735
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number62735
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: