Provider Demographics
NPI:1114027588
Name:CHELTENHAM, MARK PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PHILIP
Last Name:CHELTENHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 DODDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-9700
Mailing Address - Country:US
Mailing Address - Phone:919-761-8693
Mailing Address - Fax:
Practice Address - Street 1:628 DODDINGTON DR
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9700
Practice Address - Country:US
Practice Address - Phone:919-761-8693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-002052084P0800X
PAMD4257412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
58606OtherBOARD CERTIFICATION ABPN
NC5911546Medicaid
NC2007-00205OtherSTATE LICENSE
PAMD425741OtherLICENSE NUMBER
PAMD425741OtherLICENSE NUMBER