Provider Demographics
NPI:1861440497
Name:WHERLEY, TIMOTHY RAY
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RAY
Last Name:WHERLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:RAY
Other - Last Name:WHERLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:658 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2027
Mailing Address - Country:US
Mailing Address - Phone:330-364-5024
Mailing Address - Fax:330-364-2729
Practice Address - Street 1:658 BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2027
Practice Address - Country:US
Practice Address - Phone:330-364-5024
Practice Address - Fax:330-364-2729
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4918-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4394190001Medicare NSC