Provider Demographics
NPI:1649295833
Name:SHORT, WALTER M (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:SHORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:M
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4000 LINWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7223
Mailing Address - Country:US
Mailing Address - Phone:870-239-8503
Mailing Address - Fax:870-236-1947
Practice Address - Street 1:4000 LINWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-7224
Practice Address - Country:US
Practice Address - Phone:870-239-8503
Practice Address - Fax:870-236-1947
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1907207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135484001Medicaid
AR5K938Medicare PIN