Provider Demographics
NPI:1700828290
Name:MACINNIS, COLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MACINNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 CORLEY ISLAND RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-8292
Mailing Address - Country:US
Mailing Address - Phone:352-350-5230
Mailing Address - Fax:866-539-7193
Practice Address - Street 1:4120 CORLEY ISLAND RD
Practice Address - Street 2:SUITE 600
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8292
Practice Address - Country:US
Practice Address - Phone:352-350-5230
Practice Address - Fax:866-539-7193
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100399207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49980Medicare UPIN
FLAG808ZMedicare PIN