Provider Demographics
NPI:1629072038
Name:ACOSTA, ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
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:PO BOX 250433
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325
Mailing Address - Country:US
Mailing Address - Phone:586-929-0842
Mailing Address - Fax:248-366-0065
Practice Address - Street 1:7173 ILANAWAY DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324
Practice Address - Country:US
Practice Address - Phone:586-929-0842
Practice Address - Fax:248-366-0065
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106335602OtherBC
MI4442468Medicaid
P00193884OtherPALMETTO GBA
MI143552OtherGREAT LAKES
P00193884OtherPALMETTO GBA
MI143552OtherGREAT LAKES