Provider Demographics
NPI:1417916321
Name:CHANCELLOR, TIMOTHY LEE (OD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:CHANCELLOR
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 1:241 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-2301
Mailing Address - Country:US
Mailing Address - Phone:308-432-3222
Mailing Address - Fax:308-432-5344
Practice Address - Street 1:241 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-2301
Practice Address - Country:US
Practice Address - Phone:308-432-3222
Practice Address - Fax:308-432-5344
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD621152W00000X
NE1051152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200330Medicaid
SD9200333Medicaid
SD4993076OtherWELLMARK BCBS
NE06923OtherBCBS
410046153OtherRR MEDICARE
SD9200332Medicaid
410046153OtherRR MEDICARE
SD4993076OtherWELLMARK BCBS
SDS101740Medicare PIN
WY113730100Medicaid
SD0324130005Medicare NSC
NE265050Medicare PIN
NEE52883Medicare UPIN
NE265049Medicare PIN