Provider Demographics
NPI:1154482685
Name:STAM-CHEATHAM, ANNICK (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNICK
Middle Name:
Last Name:STAM-CHEATHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 LITTLE RIVER TPKE STE 710
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2635
Mailing Address - Country:US
Mailing Address - Phone:703-941-0267
Mailing Address - Fax:703-941-2018
Practice Address - Street 1:7617 LITTLE RIVER TPKE STE 710
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2635
Practice Address - Country:US
Practice Address - Phone:703-941-0267
Practice Address - Fax:703-941-2018
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0560207Q00000X
VA0101239148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
018504K92Medicare ID - Type Unspecified
G37792Medicare UPIN