Basic Information
Provider Information | |||||||||
NPI: | 1568444917 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEARY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7720 N CRESTLINE DR | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 616151907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096939540 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 288 N PARK ST | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | IL | ||||||||
PostalCode: | 625231306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174223881 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 06/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18002299B | IN | Y |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | OD001172 | TN | N |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 046009270 | 05 | IL |   | MEDICAID |