Provider Demographics
NPI:1689686362
Name:MCINNIS, JOHN ARTHUR (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ARTHUR
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8116 CANTERBURY LANE
Mailing Address - Street 2:#11
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551
Mailing Address - Country:US
Mailing Address - Phone:920-648-3090
Mailing Address - Fax:
Practice Address - Street 1:100 ARCADIAN AVENUE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186
Practice Address - Country:US
Practice Address - Phone:262-542-3676
Practice Address - Fax:262-542-3826
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38532200Medicaid
WI38532200Medicaid