1285920405 NPI number — NIRMALA NANDINI CHEATHAM M.D.

Table of content: NIRMALA NANDINI CHEATHAM M.D. (NPI 1285920405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285920405 NPI number — NIRMALA NANDINI CHEATHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
NIRMALA
Provider Middle Name:
NANDINI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAHARAJ
Provider Other First Name:
NIRMALA
Provider Other Middle Name:
NANDINI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285920405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847522
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-7522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-531-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2026 S JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75766-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-586-5678
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  Q2159 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: Q2159 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370083301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-1976930-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8GM804 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01812509 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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