Provider Demographics
NPI:1104436922
Name:SHEALY, KENNETH TREVOR (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:TREVOR
Last Name:SHEALY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-386-2181
Mailing Address - Fax:229-386-2193
Practice Address - Street 1:1803 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-386-2181
Practice Address - Fax:229-386-2193
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT003252OtherOPTOMETRY LICENSE