Provider Demographics
NPI:1578766804
Name:SHORT, LETITIA WINONA (MD)
Entity Type:Individual
Prefix:DR
First Name:LETITIA
Middle Name:WINONA
Last Name:SHORT
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 1:164 W 122ND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-5507
Mailing Address - Country:US
Mailing Address - Phone:443-986-3001
Mailing Address - Fax:
Practice Address - Street 1:164 W 122ND ST APT 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-5507
Practice Address - Country:US
Practice Address - Phone:443-986-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061184208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice