Provider Demographics
NPI:1619989860
Name:CHEATAM, CONSETTA MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSETTA
Middle Name:MAE
Last Name:CHEATAM
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 1:22 SYLVAN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2087
Mailing Address - Country:US
Mailing Address - Phone:201-438-8860
Mailing Address - Fax:201-438-1994
Practice Address - Street 1:22 SYLVAN ST STE 300
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2069
Practice Address - Country:US
Practice Address - Phone:201-438-8860
Practice Address - Fax:201-438-1994
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA070577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8271500Medicaid
NJ8271500Medicaid
NJ042097QBEMedicare ID - Type Unspecified