Provider Demographics
NPI:1861712150
Name:ACOSTA, RAFAEL (RAFAEL ACOSTA)
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:RAFAEL ACOSTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ELMHURST ST.
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0851
Mailing Address - Country:US
Mailing Address - Phone:949-412-8013
Mailing Address - Fax:
Practice Address - Street 1:222 W. EULALIA SUITE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2851
Practice Address - Country:US
Practice Address - Phone:818-240-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant