Provider Demographics
NPI:1467620567
Name:ACOSTA, RICHARD C
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:C
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1731
Mailing Address - Country:US
Mailing Address - Phone:520-364-3462
Mailing Address - Fax:520-805-4171
Practice Address - Street 1:1500 E 15TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1731
Practice Address - Country:US
Practice Address - Phone:520-364-3462
Practice Address - Fax:520-805-4171
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program