Provider Demographics
NPI:1447246590
Name:STREETER, THOMAS ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:STREETER
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 1:1103 JOHN SIMS PKWY E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2752
Mailing Address - Country:US
Mailing Address - Phone:850-279-4361
Mailing Address - Fax:850-279-4363
Practice Address - Street 1:1103 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2752
Practice Address - Country:US
Practice Address - Phone:850-279-4361
Practice Address - Fax:850-279-4363
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC004068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621061900Medicaid
FL28557Medicare ID - Type UnspecifiedOPTOMETRIST
FL621061900Medicaid