Provider Demographics
NPI:1083877005
Name:SHORT, MATTHEW WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:SHORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ROS CIR
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-5002
Mailing Address - Country:US
Mailing Address - Phone:509-775-3153
Mailing Address - Fax:
Practice Address - Street 1:10 ROS CIR
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-5002
Practice Address - Country:US
Practice Address - Phone:509-775-3153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61107739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA331-8907Medicaid
WA331-8907Medicaid