Provider Demographics
NPI:1700066883
Name:ACOSTA, OMETEOTL M (MD)
Entity Type:Individual
Prefix:DR
First Name:OMETEOTL
Middle Name:M
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:PO BOX 2271
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78298-2271
Mailing Address - Country:US
Mailing Address - Phone:210-481-3000
Mailing Address - Fax:210-481-3222
Practice Address - Street 1:502 MADISON OAK DR STE 210
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4192
Practice Address - Country:US
Practice Address - Phone:210-481-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9016207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281365101Medicaid
TX281365102OtherCSHCN
TX281365101Medicaid