Provider Demographics
NPI:1932502671
Name:ACOSTA, ILEANA (MD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SW 42ND AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1938
Mailing Address - Country:US
Mailing Address - Phone:305-872-0008
Mailing Address - Fax:305-928-1112
Practice Address - Street 1:401 SW 42ND AVE STE 300
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1938
Practice Address - Country:US
Practice Address - Phone:305-872-0008
Practice Address - Fax:305-928-1112
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN656208D00000X
FLACN565208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112-154-400Medicaid