Provider Demographics
NPI:1083720999
Name:SHORT, ZACHARY C (OD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:C
Last Name:SHORT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:415 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5517
Mailing Address - Country:US
Mailing Address - Phone:812-849-4555
Mailing Address - Fax:812-849-2842
Practice Address - Street 1:415 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5517
Practice Address - Country:US
Practice Address - Phone:812-849-4555
Practice Address - Fax:812-849-2842
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003418A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200826400Medicaid
IN239610Medicare PIN
IN5742930001Medicare NSC
INV10647Medicare UPIN