Provider Demographics
NPI:1053666750
Name:CHEATHAM, VICTOR L
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:L
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6545 HIGHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127
Mailing Address - Country:US
Mailing Address - Phone:313-277-0663
Mailing Address - Fax:
Practice Address - Street 1:6545 HIGHVIEW ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2126
Practice Address - Country:US
Practice Address - Phone:313-277-0663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171WV0202XOther Service ProvidersContractorVehicle Modifications
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI460530077Medicare PIN