Healthcare Provider Details

I. General information

NPI: 1053527523
Provider Name (Legal Business Name): JODY LEE SHORT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL CENTER DR STE A
SPRINGFIELD OH
45504-2688
US

IV. Provider business mailing address

200 MEDICAL CENTER DR STE A
SPRINGFIELD OH
45504-2688
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-9480
  • Fax: 937-523-9490
Mailing address:
  • Phone: 937-523-9480
  • Fax: 937-523-9490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberPENDING
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: