Provider Demographics
NPI:1629228580
Name:CHEATHAM BROWN, KARLA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KARLA
Middle Name:RENEE
Last Name:CHEATHAM BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KARLA
Other - Middle Name:RENEE
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 SUNRISE TRL
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7523
Mailing Address - Country:US
Mailing Address - Phone:618-457-2249
Mailing Address - Fax:
Practice Address - Street 1:110 SUNRISE TRL
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-7523
Practice Address - Country:US
Practice Address - Phone:618-457-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152528207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1557048Medicaid
LA1557048Medicaid