Provider Demographics
NPI:1780637868
Name:SHORT, FREDRICK WILLIAM (DO)
Entity Type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:WILLIAM
Last Name:SHORT
Suffix:
Gender:M
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:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-0996
Mailing Address - Country:US
Mailing Address - Phone:913-742-4084
Mailing Address - Fax:913-742-4086
Practice Address - Street 1:21107 DONAHOO RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-4153
Practice Address - Country:US
Practice Address - Phone:913-742-4084
Practice Address - Fax:913-742-4086
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0520840207Q00000X
MOR4C55207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
09549174OtherBCBS
KS100230280CMedicaid
KS110478Medicare PIN
C52055Medicare UPIN
KS100230280CMedicaid