Provider Demographics
NPI:1518915909
Name:SHORTER, MELANIE D (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:D
Last Name:SHORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MORAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005
Mailing Address - Country:US
Mailing Address - Phone:478-988-1282
Mailing Address - Fax:478-988-3120
Practice Address - Street 1:106 MORAN DRIVE
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005
Practice Address - Country:US
Practice Address - Phone:478-988-1282
Practice Address - Fax:478-988-3120
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA092100603DMedicaid
GA0092100603B OR CMedicaid
GA092100603DMedicaid
GA0092100603B OR CMedicaid