Provider Demographics
NPI:1154482685
Name:STAM-CHEATHAM, ANNICK (MD)
Entity type:Individual
Prefix:DR
First Name:ANNICK
Middle Name:
Last Name:STAM-CHEATHAM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:11930 DEMOCRACY DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5624
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0560207Q00000X
VA0101239148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
018504K92Medicare ID - Type Unspecified
G37792Medicare UPIN