Provider Demographics
NPI:1518940717
Name:CORLEY, JIMMIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:
Last Name:CORLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:911 HARGROVE RD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-1602
Practice Address - Country:US
Practice Address - Phone:205-507-7810
Practice Address - Fax:205-554-7399
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS771TA142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U43492Medicare UPIN
AL1074080023Medicare NSC
AL79038Medicare PIN
AL79038Medicare ID - Type Unspecified