Provider Demographics
NPI:1316940968
Name:ACOSTA, JUAN FERNANDO (DO)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:FERNANDO
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4838 45TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-7036
Mailing Address - Country:US
Mailing Address - Phone:718-433-1928
Mailing Address - Fax:718-228-4368
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-5627
Practice Address - Fax:718-960-6125
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213508207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02136170Medicaid
NY02136170Medicaid
NY828O91Medicare ID - Type Unspecified