Provider Demographics
NPI:1922281930
Name:SHELLEY, CORINNA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CORINNA
Middle Name:MARIE
Last Name:SHELLEY
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 1:2104 W GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7309
Mailing Address - Country:US
Mailing Address - Phone:209-229-8611
Mailing Address - Fax:209-229-8559
Practice Address - Street 1:2104 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-229-8611
Practice Address - Fax:209-229-8559
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13351 TPA152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy