Provider Demographics
NPI:1467497560
Name:CHEATHAM, TRACEY D (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:D
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:D
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6900 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086
Mailing Address - Country:US
Mailing Address - Phone:702-791-9000
Mailing Address - Fax:
Practice Address - Street 1:6900 N PECOS ROAD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13186208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200426730 AMedicaid
MO207205006Medicaid
MOP00410722Medicare PIN
115D314Medicare ID - Type Unspecified
MO207205006Medicaid
NVCB954ZMedicare PIN
MOX12D314Medicare PIN