Provider Demographics
NPI:1962630830
Name:STREET, LINDA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:STREET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 J DEWEY GRAY CIR STE 308
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6580
Mailing Address - Country:US
Mailing Address - Phone:706-922-7670
Mailing Address - Fax:706-863-8175
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75544207VM0101X, 207V00000X
SC32026207V00000X, 207VM0101X
NC2013-00501207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5632783OtherAETNA
NC179TKOtherBCBS
NC1962630830Medicaid
NC1962630830Medicaid