Provider Demographics
NPI:1013047166
Name:PATRICK D. SHORTER
Entity Type:Organization
Organization Name:PATRICK D. SHORTER
Other - Org Name:JONESBOROUGH EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-753-7760
Mailing Address - Street 1:805 E JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1540
Mailing Address - Country:US
Mailing Address - Phone:423-753-7760
Mailing Address - Fax:423-753-7466
Practice Address - Street 1:805 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1540
Practice Address - Country:US
Practice Address - Phone:423-753-7760
Practice Address - Fax:423-753-7466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3733327Medicaid
TN3733327Medicaid
TN3733327Medicare ID - Type UnspecifiedGROUP PROVIDER #