Provider Demographics
NPI:1639862675
Name:ACOSTA, ALFONSO (DO)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 E DELL AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2900
Mailing Address - Country:US
Mailing Address - Phone:239-321-3549
Mailing Address - Fax:
Practice Address - Street 1:1323 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4306
Practice Address - Country:US
Practice Address - Phone:405-554-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program