Provider Demographics
NPI:1306877956
Name:SHORT, DIANE ELAINE (OD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELAINE
Last Name:SHORT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:415 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5517
Mailing Address - Country:US
Mailing Address - Phone:812-333-1911
Mailing Address - Fax:812-333-1602
Practice Address - Street 1:415 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5517
Practice Address - Country:US
Practice Address - Phone:812-333-1911
Practice Address - Fax:812-404-1072
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200892700Medicaid
U18446Medicare UPIN
IN200892700Medicaid
IN0909890001Medicare NSC