Provider Demographics
NPI:1275503435
Name:SHORT, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:SHORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W. PINELOCH AVE.
Mailing Address - Street 2:SUITE 23
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:407-481-7174
Mailing Address - Fax:407-481-7190
Practice Address - Street 1:89 W. COPELAND DR.
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:407-237-6319
Practice Address - Fax:407-843-8505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME27116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42128YMedicare ID - Type Unspecified
FLD54783Medicare UPIN