Provider Demographics
NPI:1134254824
Name:CREIGHTON, DERRICK DANIEL (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:DANIEL
Last Name:CREIGHTON
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 1:2432 EAGLERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-6295
Mailing Address - Country:US
Mailing Address - Phone:573-576-2701
Mailing Address - Fax:
Practice Address - Street 1:2432 EAGLERIDGE DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-6295
Practice Address - Country:US
Practice Address - Phone:573-576-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO46165OtherGHP
MO01060802Medicaid
IL237246265001Medicaid
MO153OtherANTHEM BC/BS
TX186416701Medicaid
MO110375OtherHEALTHLINK
TX8X9731OtherBCBS
TX186416701Medicaid
MO260163Medicare Oscar/Certification
MO153OtherANTHEM BC/BS
MO01060802Medicaid