Provider Demographics
NPI:1932145513
Name:ACOSTA, IGNACIO (MD)
Entity Type:Individual
Prefix:
First Name:IGNACIO
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 1:1808 VERDUGO BLVD
Mailing Address - Street 2:SUITE 409
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-790-8020
Mailing Address - Fax:818-790-9313
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:SUITE 409
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1487
Practice Address - Country:US
Practice Address - Phone:818-790-8020
Practice Address - Fax:818-790-9313
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004033429OtherAETNA ID
CA020011428OtherRAILROAD MEDICARE
000767453OtherAPWU ID
00A266400OtherBLUE SHIELD ID
300000306091OtherPLAN HANDLERS ID
953131650OtherBLUE CROSS ID
CA00A266401Medicaid
B50038Medicare UPIN
CA00A266401Medicaid