Provider Demographics
NPI:1265530828
Name:SHORTER, ANTOINETTE MASON (MD)
Entity type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:MASON
Last Name:SHORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 NW 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4836
Mailing Address - Country:US
Mailing Address - Phone:954-370-9732
Mailing Address - Fax:
Practice Address - Street 1:4105 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8103
Practice Address - Country:US
Practice Address - Phone:954-985-1551
Practice Address - Fax:954-985-1415
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00422482083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262320000Medicaid
FL262320000Medicaid