Provider Demographics
NPI:1285660274
Name:SHORT, KATHY DARLENE (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:DARLENE
Last Name:SHORT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:317-782-1577
Mailing Address - Fax:317-780-5538
Practice Address - Street 1:828 LANE ALLEN RD STE 219
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:177-821-5773
Practice Address - Fax:317-780-5538
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007335S207Q00000X
KY03329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50031082OtherPASSPORT
KY000000694607OtherANTHEM
KY7100147240Medicaid
KYP400034758Medicare PIN
H14100Medicare UPIN