Provider Demographics
NPI:1942345228
Name:MCINNES, ALAN WALLACE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:WALLACE
Last Name:MCINNES
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:323 E RIVERSIDE DR, SUITE 136
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6865
Mailing Address - Country:US
Mailing Address - Phone:208-939-2939
Mailing Address - Fax:
Practice Address - Street 1:323 E RIVERSIDE DR, SUITE 136
Practice Address - Street 2:EAGLE
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6865
Practice Address - Country:US
Practice Address - Phone:208-939-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98662207W00000X
UT5755878-1205207W00000X
IDM11139207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1196589Medicare PIN