Individual
DR. TIMOTHY DANE SHELLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
3287 COURT ST, PEKIN, IL 61554-6208
(309) 353-9313
(309) 353-4962
Mailing address
8309 N KNOXVILLE AVE, PEORIA, IL 61615-2170
(309) 693-9540
(309) 693-9542
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046006644
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046006644
—
IL
01
—
410033413
MEDICARE RAILROAD
IL
01
—
7215175
BCBS
IL
Enumeration date
09/30/2005
Last updated
01/10/2014
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