Provider Demographics
NPI:1861404832
Name:ACOSTA, OLGA (MD)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9985 SIERRA AVE
Mailing Address - Street 2:MOB-2, MODULE 2A
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:888-750-0036
Mailing Address - Fax:
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:MOB-2, MODULE 2A
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:888-750-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62193208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A621930OtherMEDICAL PPIN #
CAG69034Medicare UPIN
CA00A621930OtherMEDICAL PPIN #