Healthcare Provider Details

I. General information

NPI: 1124878863
Provider Name (Legal Business Name): JUSTIN FORTUNE CREEDEN MD-PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W. ARBOR DRIVE MC# 8218
SAN DIEGO CA
92103
US

IV. Provider business mailing address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 619-471-0283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number203584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: