Provider Demographics
NPI:1437136306
Name:ACOSTA, KATRINA (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 ELM ST
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-4921
Mailing Address - Country:US
Mailing Address - Phone:603-543-3409
Mailing Address - Fax:503-543-8981
Practice Address - Street 1:243 ELM ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-4921
Practice Address - Country:US
Practice Address - Phone:603-543-3409
Practice Address - Fax:503-543-8981
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH138912085R0202X
VT042-00115372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30207693Medicaid
IL36106241Medicaid
VT000528202Medicare PIN
IL36106241Medicaid
NH30207693Medicaid
NH000528201Medicare PIN
ILK06109Medicare ID - Type Unspecified