Provider Demographics
NPI:1891806022
Name:SHELLEY, TERRY D (OD)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:D
Last Name:SHELLEY
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 1:1608 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2205
Mailing Address - Country:US
Mailing Address - Phone:765-289-4727
Mailing Address - Fax:765-751-2207
Practice Address - Street 1:1608 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2205
Practice Address - Country:US
Practice Address - Phone:765-289-4727
Practice Address - Fax:765-751-2207
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001461B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100150060AMedicaid
U01928Medicare UPIN
204750BMedicare ID - Type Unspecified