Provider Demographics
NPI:1477616167
Name:ACOSTA, IVAN RAFAEL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:RAFAEL
Last Name:ACOSTA
Suffix:SR
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:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-1477
Mailing Address - Country:US
Mailing Address - Phone:787-892-5730
Mailing Address - Fax:787-264-4221
Practice Address - Street 1:CALLE TETUAN#4
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-5730
Practice Address - Fax:787-264-4221
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC79586Medicare UPIN
PR27973ACMedicare ID - Type Unspecified