Provider Demographics
NPI:1780813311
Name:SHORT, TRACEE CHAVAWN (MD)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:CHAVAWN
Last Name:SHORT
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 1:8490 PICARDY AVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3731
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:STE 200-B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-381-2615
Practice Address - Fax:225-381-2638
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6871208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA324582YUB6OtherMEDICARE PTAN
LA2347799Medicaid
LA2347799Medicaid