Provider Demographics
NPI:1912994773
Name:STREETER, DENNIS LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LYNN
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 1:300 W 80TH PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5456
Mailing Address - Country:US
Mailing Address - Phone:219-791-9782
Mailing Address - Fax:219-791-9787
Practice Address - Street 1:300 W 80TH PL
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5456
Practice Address - Country:US
Practice Address - Phone:219-791-9782
Practice Address - Fax:219-791-9787
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020000320B208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000235OtherILLINOIS BC/BS
IN100166240Medicaid
IN000000084728OtherIND BLUE CROSS
INB29008Medicare UPIN
IN100166240Medicaid