Provider Demographics
NPI:1770570970
Name:SHOLEY, TODD E (OD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:SHOLEY
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 1:544 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6346
Mailing Address - Country:US
Mailing Address - Phone:307-382-3937
Mailing Address - Fax:307-382-2918
Practice Address - Street 1:544 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6346
Practice Address - Country:US
Practice Address - Phone:307-382-3937
Practice Address - Fax:307-382-2918
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY205T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103246100Medicaid
WY410036453Medicare PIN
WYU32368Medicare UPIN
WY103246100Medicaid
WY4978190001Medicare NSC