Provider Demographics
NPI:1902833866
Name:ACOSTA, RESTITUTO B (MD)
Entity Type:Individual
Prefix:DR
First Name:RESTITUTO
Middle Name:B
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 1:117 WEST LIBERTY ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440
Mailing Address - Country:US
Mailing Address - Phone:315-337-2582
Mailing Address - Fax:315-337-2582
Practice Address - Street 1:117 WEST LIBERTY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-337-2582
Practice Address - Fax:315-337-2582
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601696Medicaid
NYRA4719Medicare ID - Type Unspecified
NY02601696Medicaid