Healthcare Provider Details

I. General information

NPI: 1447246590
Provider Name (Legal Business Name): THOMAS ALLEN STREETER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SWIFT CREEK CT
NICEVILLE FL
32578-3710
US

IV. Provider business mailing address

100 SWIFT CREEK CT
NICEVILLE FL
32578-3710
US

V. Phone/Fax

Practice location:
  • Phone: 850-758-5981
  • Fax:
Mailing address:
  • Phone: 850-758-5981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC004068
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: