Provider Demographics
NPI:1538176227
Name:SHELLEY, BRENT EDWARD (OD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:EDWARD
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 1:1400 COMMON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5922
Mailing Address - Country:US
Mailing Address - Phone:915-595-4375
Mailing Address - Fax:915-595-4460
Practice Address - Street 1:1400 COMMON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5922
Practice Address - Country:US
Practice Address - Phone:915-595-4375
Practice Address - Fax:915-595-4460
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2549152W00000X
TX9924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91360OtherPRESBYTERIAN HEALTH INS
NM200151153OtherUNITED HEALTH CARE
NM200151153OtherTRICARE
NMNM00PB21OtherBCBS OF NM