Provider Demographics
NPI:1396701207
Name:ACOSTA, JORGE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
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 1:10201 GATEWAY BLVD W STE 100
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7647
Mailing Address - Country:US
Mailing Address - Phone:915-250-0220
Mailing Address - Fax:915-250-0632
Practice Address - Street 1:10201 GATEWAY BLVD W STE 100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7647
Practice Address - Country:US
Practice Address - Phone:915-250-0220
Practice Address - Fax:915-250-0632
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6246208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166864201Medicaid
TXH91941Medicare UPIN
H91941Medicare UPIN
TX8C1727Medicare PIN