Provider Demographics
NPI:1033189956
Name:MCINNIS, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:252 MATLOCK RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6413
Mailing Address - Country:US
Mailing Address - Phone:817-473-7184
Mailing Address - Fax:817-473-7186
Practice Address - Street 1:252 MATLOCK RD
Practice Address - Street 2:SUITE 130
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6413
Practice Address - Country:US
Practice Address - Phone:817-473-7184
Practice Address - Fax:817-473-7186
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL5834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159747801Medicaid
8A8197Medicare ID - Type Unspecified
TX159747801Medicaid