Provider Demographics
NPI:1235176520
Name:SHORT, JOHN P (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:SHORT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3860
Mailing Address - Country:US
Mailing Address - Phone:864-725-4780
Mailing Address - Fax:864-725-4778
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4780
Practice Address - Fax:864-725-4778
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1982207P00000X
SC2001207Q00000X
SC1651207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC016510Medicaid
OH2774136Medicaid
WV1811051000Medicaid
OH2774136Medicaid
SC016510Medicaid
WVI06287Medicare UPIN
WV1811051000Medicaid
0931048Medicare PIN