Provider Demographics
NPI:1992706451
Name:CHEATHAM-LOTT, MARTA (MD)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:CHEATHAM-LOTT
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-335-9951
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-335-9951
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55758207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A557580Medicaid
G80155Medicare UPIN
W14422CMedicare ID - Type Unspecified