Provider Demographics
NPI:1497761381
Name:SHORT, BRUCE J (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:SHORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 STERLING RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3869
Mailing Address - Country:US
Mailing Address - Phone:703-481-4400
Mailing Address - Fax:703-935-0430
Practice Address - Street 1:1041 STERLING RD
Practice Address - Street 2:SUITE 101
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3869
Practice Address - Country:US
Practice Address - Phone:703-481-4400
Practice Address - Fax:703-935-0430
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555886111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF964-0001OtherCAREFIRST BC/BS