Provider Demographics
NPI:1629223318
Name:STREETER, MICHAEL ALLAN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLAN
Last Name:STREETER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4252
Mailing Address - Fax:317-865-8318
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-757-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003350A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000722408OtherANTHEM TRADITIONAL
IN200926260Medicaid
IN200926260Medicaid
INM400049704Medicare PIN