Basic Information
| Provider Information | |||||||||
| NPI: | 1275929598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | ENRIQUE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ACOSTA | ||||||||
| OtherFirstName: | ENRIQUE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 N BECKLEY AVE STE 370 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752031259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 019587 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | T5248 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | T5248 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | T5248 | 01 | TX | TX MEDICAL LICENSE | OTHER |