Healthcare Provider Details

I. General information

NPI: 1669907192
Provider Name (Legal Business Name): TYLER KENT SHORT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CTR 34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

NAVAL MEDICAL CTR 34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-5998
  • Fax: 619-532-5507
Mailing address:
  • Phone: 619-532-5998
  • Fax: 619-532-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number193406
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number193406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: