Provider Demographics
NPI:1962556118
Name:SHANEYFELT, CORNELIUS J (OD)
Entity type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:J
Last Name:SHANEYFELT
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:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:KNIGHTSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46148-0025
Mailing Address - Country:US
Mailing Address - Phone:765-345-5405
Mailing Address - Fax:765-345-5405
Practice Address - Street 1:12 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KNIGHTSTOWN
Practice Address - State:IN
Practice Address - Zip Code:46148-1243
Practice Address - Country:US
Practice Address - Phone:765-345-5405
Practice Address - Fax:765-345-5405
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001864B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100183230AMedicaid
IN100183230AMedicaid
INU25861Medicare UPIN