Provider Demographics
NPI:1942767876
Name:ACOSTA ENRRIQUEZ, ELISEO (MD)
Entity Type:Individual
Prefix:
First Name:ELISEO
Middle Name:
Last Name:ACOSTA ENRRIQUEZ
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 1:1400 NW 107TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2746
Mailing Address - Country:US
Mailing Address - Phone:305-534-0076
Mailing Address - Fax:
Practice Address - Street 1:7495 N UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321
Practice Address - Country:US
Practice Address - Phone:954-306-9037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1170208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108255400Medicaid
M9167OtherMEDICARE