Provider Demographics
NPI:1235549361
Name:CHEATHAM, BROOKE HASTINGS (DO)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:HASTINGS
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:BROOKE
Other - Last Name:HASTINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1305 ESCALENTE DRIVE
Mailing Address - Street 2:UNIT 205
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303
Mailing Address - Country:US
Mailing Address - Phone:970-259-1971
Mailing Address - Fax:970-259-4036
Practice Address - Street 1:1305 ESCALENTE DRIVE
Practice Address - Street 2:UNIT 205
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303
Practice Address - Country:US
Practice Address - Phone:970-259-1971
Practice Address - Fax:970-259-4036
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0059781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
COFC7319913OtherDEA