MEDICARE: LISA A MATTINGLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME146476	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	430265YRHZ	OTHER	OK	MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104186907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A MATTINGLY MD

Provider Business Mailing Address
First Line	:	2710 REW CIR STE 200
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-2967
Country	:	US
Telephone Number	:	888-373-0013
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 LOVELAND BLVD
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-1813
Country	:	US
Telephone Number	:	941-764-0301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2012
Last Update Date	:	05/01/2026

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