Provider Demographics
NPI:1750594693
Name:FERNANDEZ ACOSTA, CARLOS A (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:FERNANDEZ 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 1:849 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4614
Mailing Address - Country:US
Mailing Address - Phone:843-497-6348
Mailing Address - Fax:843-497-6351
Practice Address - Street 1:849 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4614
Practice Address - Country:US
Practice Address - Phone:843-497-6348
Practice Address - Fax:843-497-6351
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
GA069805208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC037336700Medicaid
SC037336700Medicaid