Provider Demographics
NPI:1194463034
Name:STREETY, MITCHELL DERRICK
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:DERRICK
Last Name:STREETY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 FOX MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2885
Mailing Address - Country:US
Mailing Address - Phone:716-544-2991
Mailing Address - Fax:
Practice Address - Street 1:95 FOX MEADOW LN
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2885
Practice Address - Country:US
Practice Address - Phone:716-544-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program