MEDICARE: DYLAN C CREAMER ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PS0010X	Sports Medicine (Emergency Medicine) Physician	200002964	CA

General Provider Information

NPI Number	:	1740797307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN C CREAMER ATC

Provider Business Mailing Address
First Line	:	1157 REED AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5107
Country	:	US
Telephone Number	:	619-917-3611
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1507
Country	:	US
Telephone Number	:	619-917-3611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2018
Last Update Date	:	01/04/2018

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