Healthcare Provider Details

I. General information

NPI: 1700828290
Provider Name (Legal Business Name): COLLEEN MACINNIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 CORLEY ISLAND RD SUITE 600
LEESBURG FL
34748-8292
US

IV. Provider business mailing address

4120 CORLEY ISLAND RD SUITE 600
LEESBURG FL
34748-8292
US

V. Phone/Fax

Practice location:
  • Phone: 352-350-5230
  • Fax: 866-539-7193
Mailing address:
  • Phone: 352-350-5230
  • Fax: 866-539-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME100399
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: