Provider Demographics
NPI:1649474800
Name:I. ACOSTA, M.D., INC.
Entity type:Organization
Organization Name:I. ACOSTA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-790-8020
Mailing Address - Street 1:1808 VERDUGO BLVD
Mailing Address - Street 2:SUITE 409
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-790-8020
Mailing Address - Fax:818-790-9313
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:SUITE 409
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1477
Practice Address - Country:US
Practice Address - Phone:818-790-8020
Practice Address - Fax:818-790-9313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO4784OtherRAILROAD MEDICARE PTAN
CA0004033429OtherAETNA ID
CA00A266400OtherBLUE SHIELD ID
CA00A266401Medicaid
CA000767453OtherAPWU ID
CA300000306091OtherPLAN HANDLERS ID
DO4784OtherRAILROAD MEDICARE PTAN
CA300000306091OtherPLAN HANDLERS ID
CA=========OtherHEALTHNET ID
CAB50038Medicare UPIN
DO4784OtherRAILROAD MEDICARE PTAN