Provider Demographics
NPI:1598334898
Name:STREETER, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
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 1:1650 COCHRANE CIR UNIT MEDDAC
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7450
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR UNIT MEDDAC
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGMedicaid