Provider Demographics
NPI:1356319743
Name:SHORT, RONALD B (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:B
Last Name:SHORT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:VINCENT
Other - Middle Name:
Other - Last Name:DANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:147 CALLA AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1003
Mailing Address - Country:US
Mailing Address - Phone:619-628-1728
Mailing Address - Fax:
Practice Address - Street 1:3955 BONITA RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1230
Practice Address - Country:US
Practice Address - Phone:619-409-9997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8028 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist