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 1:2514 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3509
Mailing Address - Country:US
Mailing Address - Phone:711-322-3097
Mailing Address - Fax:712-322-4130
Practice Address - Street 1:2514 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3509
Practice Address - Country:US
Practice Address - Phone:712-322-3097
Practice Address - Fax:712-322-4130
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1267152W00000X
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