Provider Demographics
NPI:1841306008
Name:SHORT, LAWRENCE ALAN (DPM)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALAN
Last Name:SHORT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:71 WAUKEGAN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-3009
Mailing Address - Country:US
Mailing Address - Phone:847-295-9301
Mailing Address - Fax:847-295-9607
Practice Address - Street 1:71 WAUKEGAN ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1662
Practice Address - Country:US
Practice Address - Phone:847-295-9301
Practice Address - Fax:847-295-9607
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL016003095213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60021233OtherBCBS
IL363267075OtherHUMANA
IL363267075OtherUNICARE
IL000102466006OtherUNITED HEALTH CARE
IL2502493OtherCIGNA
IL2137407OtherAETNA
IL363267075OtherUNICARE
IL672090Medicare PIN