Provider Demographics
NPI:1659699833
Name:SHORT, CHRISTY D (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:D
Last Name:SHORT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138762207P00000X
390200000X
WI60834-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659699833OtherBCBSWI
WI1659699833Medicaid
IL388608210 1Medicaid
WISHORTCHROtherMERCYCARE INSURANCE
WI1659699833OtherBCBSWI