Provider Demographics
NPI:1083615595
Name:ACOSTA-CORRALES, MANUEL L (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:L
Last Name:ACOSTA-CORRALES
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 1:1655 MOSSWOOD ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-3435
Mailing Address - Country:US
Mailing Address - Phone:915-591-7700
Mailing Address - Fax:915-591-3170
Practice Address - Street 1:1655 MOSSWOOD ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-3435
Practice Address - Country:US
Practice Address - Phone:915-591-7700
Practice Address - Fax:915-591-3170
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3635208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031804001Medicaid
TX00AA40Medicare PIN
TXB20776Medicare UPIN