Provider Demographics
NPI:1639118805
Name:SHORT, VALERIE (MD)
Entity Type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:
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:PO BOX 3437
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-3437
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-981-2016
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:601-981-2016
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13295207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110568Medicaid
MS160000597Medicare Oscar/Certification
MSS58869Medicare UPIN