Provider Demographics
NPI:1962481234
Name:SHORTLIDGE, STEPHEN CHANNING (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHANNING
Last Name:SHORTLIDGE
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:8960 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9470
Practice Address - Fax:239-343-9498
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS4566OtherLIC
E32257Medicare UPIN
FLOS4566OtherLIC