1568567493 NPI number — DR. BOBBY DON CHEATHAM DDS

Table of content: DR. BOBBY DON CHEATHAM DDS (NPI 1568567493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568567493 NPI number — DR. BOBBY DON CHEATHAM DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
BOBBY
Provider Middle Name:
DON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568567493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4205 CHERRY HILL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120-8105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-755-9837
Provider Business Mailing Address Fax Number:
405-752-2091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 NORTH KELLY AVENUE
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73003-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-562-2222
Provider Business Practice Location Address Fax Number:
405-562-2200
Provider Enumeration Date:
09/14/2006

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: 1223P0221X , with the licence number:  422062SPECIALTY , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100123080A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100123080D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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