Provider Demographics
NPI:1801002837
Name:MCINNIS, JUSTIN M (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:203 NACOGDOCHES ST STE 280
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2444
Mailing Address - Country:US
Mailing Address - Phone:903-541-5390
Mailing Address - Fax:903-541-5393
Practice Address - Street 1:203 NACOGDOCHES ST STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2444
Practice Address - Country:US
Practice Address - Phone:903-541-5390
Practice Address - Fax:903-541-5393
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXN0262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine