Provider Demographics
NPI:1891807210
Name:STREETER, GREGORY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DEAN
Last Name:STREETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DOCTORS DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-353-0565
Mailing Address - Fax:910-353-3940
Practice Address - Street 1:200 DOCTOR DR
Practice Address - Street 2:SUITE H
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-353-0565
Practice Address - Fax:910-353-3940
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8980340Medicaid
NC80340OtherBLUE CROSS BLUE SHIELD
NC202953Medicare ID - Type Unspecified
NC8980340Medicaid