Provider Demographics
NPI:1255450771
Name:MATTINGLY, JAY STUART (OD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:STUART
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2550 W FM 875
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5916
Mailing Address - Country:US
Mailing Address - Phone:972-775-1663
Mailing Address - Fax:
Practice Address - Street 1:150 N INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1844
Practice Address - Country:US
Practice Address - Phone:972-223-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX3661T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist