Provider Demographics
NPI:1164478590
Name:SHORT, MARGO RENEE (MD)
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:RENEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S 5TH ST
Mailing Address - Street 2:STE 202
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5861
Mailing Address - Country:US
Mailing Address - Phone:580-297-5340
Mailing Address - Fax:580-297-5344
Practice Address - Street 1:330 S 5TH ST
Practice Address - Street 2:STE 202
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5861
Practice Address - Country:US
Practice Address - Phone:580-297-5340
Practice Address - Fax:580-297-5344
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200085930BMedicaid
OK453598YPW9Medicare PIN
OKI67058Medicare UPIN