Healthcare Provider Details

I. General information

NPI: 1265995492
Provider Name (Legal Business Name): JUSTIN DANIEL SHORTELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2019
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 MASSACHUSETTS AVE NW STE 21
WASHINGTON DC
20016-4360
US

IV. Provider business mailing address

4910 MASSACHUSETTS AVE NW STE 21
WASHINGTON DC
20016-4360
US

V. Phone/Fax

Practice location:
  • Phone: 202-686-6700
  • Fax: 202-464-0208
Mailing address:
  • Phone: 202-686-6700
  • Fax: 202-464-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101281873
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD500002813
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: