Basic Information
| Provider Information | |||||||||
| NPI: | 1588985253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | DATHON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218415142 | ||||||||
| FaxNumber: | 4076483686 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218415142 | ||||||||
| FaxNumber: | 4076483686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TRN15234 | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.