Provider Demographics
NPI:1336116383
Name:SHORT, BRIAN (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHORT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1921
Mailing Address - Country:US
Mailing Address - Phone:513-735-8924
Mailing Address - Fax:513-732-8348
Practice Address - Street 1:6200 PLEASANT AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4670
Practice Address - Country:US
Practice Address - Phone:513-829-9333
Practice Address - Fax:513-858-7827
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003369213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2502661Medicaid
OH4132722Medicare PIN
OH2502661Medicaid
OH7580620001Medicare NSC