Provider Demographics
NPI:1144304544
Name:ACOSTA, DANIEL T
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 C ST
Mailing Address - Street 2:APT. 502
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5381
Mailing Address - Country:US
Mailing Address - Phone:619-235-8950
Mailing Address - Fax:619-235-8959
Practice Address - Street 1:635 C ST
Practice Address - Street 2:APT. 502
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5381
Practice Address - Country:US
Practice Address - Phone:619-235-8950
Practice Address - Fax:619-235-8959
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02268ZOtherBLUE SHIELD
CADXX00002FMedicaid
CA0251700001Medicare NSC