Basic Information
| Provider Information | |||||||||
| NPI: | 1568552727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8881 FLETCHER PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194646434 | ||||||||
| FaxNumber: | 6194645109 | ||||||||
| Practice Location | |||||||||
| Address1: | 8881 FLETCHER PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194646434 | ||||||||
| FaxNumber: | 6194645109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G37177 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.