Provider Demographics
NPI:1972377612
Name:ACOSTA, IVANKA (OD)
Entity Type:Individual
Prefix:
First Name:IVANKA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 NW 79TH AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6581
Mailing Address - Country:US
Mailing Address - Phone:305-748-5185
Mailing Address - Fax:
Practice Address - Street 1:3825 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5502
Practice Address - Country:US
Practice Address - Phone:305-554-0693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist