Provider Demographics
NPI:1003951641
Name:ACOSTA, SUSAN C
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12405 SUN TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4609
Mailing Address - Country:US
Mailing Address - Phone:915-373-5256
Mailing Address - Fax:
Practice Address - Street 1:1991 SAUL KLEINFELD DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-3757
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676559Medicare Oscar/Certification
TX676552Medicare Oscar/Certification
TX676554Medicare Oscar/Certification
TX676600Medicare Oscar/Certification
TX676626Medicare Oscar/Certification
TX00936XMedicare ID - Type UnspecifiedPART B GROUP NUMBER
TX676564Medicare Oscar/Certification
TX676555Medicare Oscar/Certification