Provider Demographics
NPI:1417164450
Name:CREAMER, MAILY TARA (DO)
Entity Type:Individual
Prefix:DR
First Name:MAILY
Middle Name:TARA
Last Name:CREAMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MAILY
Other - Middle Name:TARA
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:510 SUPERIOR AVE
Mailing Address - Street 2:STE 200B
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-791-3001
Mailing Address - Fax:949-791-3096
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:STE 200B
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3663
Practice Address - Country:US
Practice Address - Phone:949-791-3001
Practice Address - Fax:949-791-3096
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9324207R00000X, 208000000X
FLOS11017207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002548900Medicaid
FL1494AOtherBCBSFL
FLDL104ZMedicare PIN
CABB723TMedicare PIN