Provider Demographics
NPI:1194735613
Name:SHORT, HERBERT D III (MD)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:D
Last Name:SHORT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 EAST HOUSTON
Practice Address - Street 2:STE 530
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-525-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1941208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134247909Medicaid
TX8G9114Medicare Oscar/Certification
TXP00633783Medicare PIN
TX8G9114Medicare ID - Type Unspecified
TXC21780Medicare UPIN