Provider Demographics
NPI:1467423772
Name:ACOSTA, JUAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:M
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 1:52565 CESAR CHAVEZ ST STE 104
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1534
Mailing Address - Country:US
Mailing Address - Phone:760-398-0606
Mailing Address - Fax:760-398-5507
Practice Address - Street 1:52565 CESAR CHAVEZ ST STE 104
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1534
Practice Address - Country:US
Practice Address - Phone:760-398-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA665952086S0120X, 208D00000X
AZ352202086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ078584Medicaid
AZ78584Medicare PIN
AZ078584Medicaid