Provider Demographics
NPI:1912917857
Name:SHORT, ALICE SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:SUSAN
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 1:6652 TRODENT WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108
Mailing Address - Country:US
Mailing Address - Phone:239-262-3669
Mailing Address - Fax:239-262-2031
Practice Address - Street 1:3425 10TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3806
Practice Address - Country:US
Practice Address - Phone:239-262-3669
Practice Address - Fax:239-262-2031
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23952208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD52104Medicare UPIN
FL11096Medicare ID - Type Unspecified