=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952355786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A MATTINGLY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 WOLF CREEK DR
-----------------------------------------------------
City | SWANSEA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-277-7912
-----------------------------------------------------
Fax | 618-277-7915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 E FAIRWAY DR
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62223-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-304-8392
-----------------------------------------------------
Fax | 443-451-8601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 036096843
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 103379
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 42628
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 01066438A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | D0068341
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 42628
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 103379
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 01066438A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | D0068341
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036096843
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------