Provider Demographics
NPI:1962464156
Name:STREET, DEXTER WAYNE (OD)
Entity Type:Individual
Prefix:MR
First Name:DEXTER
Middle Name:WAYNE
Last Name:STREET
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 1:913 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-4459
Mailing Address - Country:US
Mailing Address - Phone:336-786-8828
Mailing Address - Fax:336-786-5977
Practice Address - Street 1:913 WORTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4459
Practice Address - Country:US
Practice Address - Phone:336-786-8828
Practice Address - Fax:336-786-5977
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA431657OtherANTHEM
NC09878OtherBLUE CROSS BLUE SHIELD
NC7909878Medicaid
NC410038739OtherRAILROAD MEDICARE
NC2208005OtherUNITED HEALTHCARE
VA431657OtherANTHEM
NC2467236AMedicare PIN
NCT21682Medicare UPIN