Healthcare Provider Details

I. General information

NPI: 1811157969
Provider Name (Legal Business Name): JOHN MICHAEL STREACKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 MEDICAL DR
TALLAHASSEE FL
32308-4615
US

IV. Provider business mailing address

1541 MEDICAL DR
TALLAHASSEE FL
32308-4615
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-2273
  • Fax: 850-431-7809
Mailing address:
  • Phone: 850-431-2273
  • Fax: 850-431-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN12963
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME105310
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: