Provider Demographics
NPI:1699762047
Name:SHELLEY, TIMOTHY DANE (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DANE
Last Name:SHELLEY
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 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:3287 COURT ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6208
Practice Address - Country:US
Practice Address - Phone:309-353-9313
Practice Address - Fax:309-353-4962
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410033413OtherMEDICARE RAILROAD
IL046006644Medicaid
IL7215175OtherBCBS
IL0295700012Medicare NSC
ILK04666Medicare PIN
IL7215175OtherBCBS