Provider Demographics
NPI:1811962145
Name:STREETER, THOMAS T (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
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:P.O. BOX 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-334-1800
Mailing Address - Fax:209-334-1430
Practice Address - Street 1:2509 W MARCH LN
Practice Address - Street 2:SUITE 250
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8252
Practice Address - Country:US
Practice Address - Phone:209-957-1000
Practice Address - Fax:209-957-1001
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23450174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A234500Medicaid
CA1386636165OtherGROUP NPI
CA68-0277719OtherTAX ID NUMBER
CAA234500Medicare UPIN
CA68-0277719OtherTAX ID NUMBER