Provider Demographics
NPI:1134184153
Name:SHORT, DAVID GEORGE (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:GEORGE
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 1:1025 MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1594
Mailing Address - Country:US
Mailing Address - Phone:574-753-2222
Mailing Address - Fax:574-753-0522
Practice Address - Street 1:1025 MICHIGAN AVENUE
Practice Address - Street 2:SUITE 215
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1594
Practice Address - Country:US
Practice Address - Phone:574-753-2222
Practice Address - Fax:574-753-0522
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001212A207KA0200X, 207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN265973OtherHARMONY
IN000000090844OtherANTHEM
IN000000596741OtherANTHEM (LMH)
IN5231880002OtherCIGNA
IN1019948OtherTRICARE
IN0004358987OtherAETNA
IN100071010Medicaid
IN356001853017OtherTRICARE
IN940670C1Medicare PIN
IN5231880002OtherCIGNA
INB48469Medicare UPIN