Provider Demographics
NPI:1780813311
Name:SHORT, TRACEE CHAVAWN (MD)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:CHAVAWN
Last Name:SHORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9618 JEFFERSON HWY STE D149
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9636
Mailing Address - Country:US
Mailing Address - Phone:478-276-0513
Mailing Address - Fax:
Practice Address - Street 1:9618 JEFFERSON HWY STE D149
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9636
Practice Address - Country:US
Practice Address - Phone:478-276-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6871208D00000X
390200000X
LAMD.206571208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2347799Medicaid
LA324582YUB6OtherMEDICARE PTAN
LA2347799Medicaid