Provider Demographics
NPI:1053321679
Name:INNIS, JEFFREY WINFIELD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WINFIELD
Last Name:INNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-0210
Mailing Address - Fax:239-343-4236
Practice Address - Street 1:23450 VIA COCONUT PT
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-1877
Practice Address - Country:US
Practice Address - Phone:239-468-0210
Practice Address - Fax:239-343-4236
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058671207SG0201X, 208000000X
FLME152778207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113233700Medicaid
MI2774825Medicaid
MI2774825Medicaid