Healthcare Provider Details

I. General information

NPI: 1306119342
Provider Name (Legal Business Name): LOUISE JOY SHORT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 FARMBROOKE CT
ATLANTA GA
30350-5662
US

IV. Provider business mailing address

225 FARMBROOKE CT
ATLANTA GA
30350-5662
US

V. Phone/Fax

Practice location:
  • Phone: 404-664-9203
  • Fax:
Mailing address:
  • Phone: 404-664-9203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35518
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number35518
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number35518
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: