Provider Demographics
NPI:1831147933
Name:ACOSTA, JOSE R (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:ACOSTA
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 1:400 HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-1167
Mailing Address - Country:US
Mailing Address - Phone:717-242-7707
Mailing Address - Fax:717-242-7083
Practice Address - Street 1:27 SANDY LANE
Practice Address - Street 2:SUITE 140
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1318
Practice Address - Country:US
Practice Address - Phone:717-242-2711
Practice Address - Fax:717-248-0502
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038970L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA060000161OtherRAILROAD MEDICARE
PA02552500OtherCAPITAL BLUE CROSS
PA076706OtherBLUE SHIELD
PA0008056460001Medicaid
PA000805646Medicaid
PAC30466Medicare UPIN
PA0008056460001Medicaid
112094Medicare PIN