Healthcare Provider Details

I. General information

NPI: 1992035695
Provider Name (Legal Business Name): MACINNIS DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27950 US HIGHWAY 27
LEESBURG FL
34748-9050
US

IV. Provider business mailing address

PO BOX 490558
LEESBURG FL
34749-0558
US

V. Phone/Fax

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

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: COLLEEN MACINNIS
Title or Position: OWNER
Credential: M.D.
Phone: 352-350-5230