Provider Demographics
NPI:1255309985
Name:ACOSTA, EDWIN R (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:R
Last Name:ACOSTA
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 1:100 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1318
Mailing Address - Country:US
Mailing Address - Phone:607-734-6237
Mailing Address - Fax:607-734-9728
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-734-3414
Practice Address - Fax:607-734-9728
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207426-12085R0202X
NY2074262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1667956Medicaid
NY01759677Medicaid
NY01759677Medicaid
PA008662Medicare ID - Type Unspecified
PA1667956Medicaid