Provider Demographics
NPI:1568568384
Name:CHEATHAM, KYLE M (O D)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:M
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 NICHOLAS ST
Mailing Address - Street 2:STE 250
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2149
Mailing Address - Country:US
Mailing Address - Phone:402-493-6500
Mailing Address - Fax:402-493-4370
Practice Address - Street 1:9900 NICHOLAS ST
Practice Address - Street 2:STE 250
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2149
Practice Address - Country:US
Practice Address - Phone:402-493-6500
Practice Address - Fax:402-493-4370
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02373152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA99831OtherBCBS
NEP00397521OtherPALMETTO RAILROAD
IA0790470Medicaid
NE10025382400Medicaid
IA99644OtherBCBS
IA614965001OtherDMERC
IA32830OtherBCBS OF IA
NE37153OtherBCBS OF NE
NE37192OtherBCBS OF NE
IAIB1076001Medicare PIN
IA614965001OtherDMERC
NE281636Medicare PIN
NE37192OtherBCBS OF NE