Provider Demographics
NPI:1558976696
Name:ACOSTA, CARLO (BSMT)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:BSMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MELBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4636
Mailing Address - Country:US
Mailing Address - Phone:917-545-2065
Mailing Address - Fax:
Practice Address - Street 1:7 W 51ST ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6905
Practice Address - Country:US
Practice Address - Phone:212-651-7515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010446156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist