Provider Demographics
NPI:1184046815
Name:SHORT, MICHAEL THOMAS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15034 AVENIDA MONTUOSA
Mailing Address - Street 2:APT B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1442
Mailing Address - Country:US
Mailing Address - Phone:949-682-6918
Mailing Address - Fax:
Practice Address - Street 1:15034 AVENIDA MONTUOSA
Practice Address - Street 2:APT B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-1442
Practice Address - Country:US
Practice Address - Phone:949-682-6918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman