Provider Demographics
NPI:1235240169
Name:MABEN, TAMRA GLADYS MAYNIE (MD)
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:GLADYS MAYNIE
Last Name:MABEN
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 1:5325 FOLKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3271
Mailing Address - Country:US
Mailing Address - Phone:248-227-0258
Mailing Address - Fax:
Practice Address - Street 1:5325 FOLKSTONE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3271
Practice Address - Country:US
Practice Address - Phone:248-227-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086192A207Q00000X
MI4301068281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC6755OtherMCARE
MI0808113911OtherBCBS
MI700H110750OtherBCBS
MIC6755OtherMCARE
MI0N10070017Medicare ID - Type Unspecified