Provider Demographics
NPI:1285645564
Name:ACOSTA, RUDOLPH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:
Last Name:ACOSTA
Suffix:JR
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 1:12408 N 56TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617
Mailing Address - Country:US
Mailing Address - Phone:813-980-3104
Mailing Address - Fax:813-980-3106
Practice Address - Street 1:12408 N 56TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617
Practice Address - Country:US
Practice Address - Phone:813-980-3104
Practice Address - Fax:813-980-3106
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1642018006OtherCIGNA
FL260315200Medicaid
FL340001936OtherRAILROAD MEDICARE
FL0451879OtherAETNA
D54167Medicare UPIN
FL260315200Medicaid