Provider Demographics
NPI:1952307860
Name:SHORT, HAROLD KEITH (MD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:KEITH
Last Name:SHORT
Suffix:
Gender:M
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-0309
Mailing Address - Country:US
Mailing Address - Phone:501-985-5900
Mailing Address - Fax:501-985-6016
Practice Address - Street 1:1300 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-985-5900
Practice Address - Fax:501-985-6016
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105321001Medicaid
AR105321001Medicaid
54827Medicare ID - Type Unspecified