Provider Demographics
NPI:1467489161
Name:STROETKER, JOSEPH A (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:STROETKER
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:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-0457
Mailing Address - Country:US
Mailing Address - Phone:573-468-4032
Mailing Address - Fax:
Practice Address - Street 1:280 E SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1364
Practice Address - Country:US
Practice Address - Phone:573-468-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0204770001OtherMEDICARE NSC #
MO312334105Medicaid
MO0204770001OtherMEDICARE NSC #
MO990001581Medicare ID - Type Unspecified