Healthcare Provider Details

I. General information

NPI: 1568552727
Provider Name (Legal Business Name): RICHARD LEE SHORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 FLETCHER PKWY SUITE 200
LA MESA CA
91942-3134
US

IV. Provider business mailing address

8881 FLETCHER PARKWAY SUITE 200
LA MESA CA
91942-3135
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-6434
  • Fax: 619-464-5109
Mailing address:
  • Phone: 619-464-6434
  • Fax: 619-464-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG37177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: