Provider Demographics
NPI:1346382314
Name:COLLINGHAM, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COLLINGHAM
Suffix:
Gender:M
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 9017
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-9001
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:1656 N CALIFORNIA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4180
Practice Address - Country:US
Practice Address - Phone:925-937-5214
Practice Address - Fax:925-937-5936
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90070207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A900700Medicaid
CA00A900703Medicare PIN
CAI34078Medicare UPIN