=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134559123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EFRAIN ACOSTA-LEON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 S COLORADO AVE STE 111A
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-513-6588
-----------------------------------------------------
Fax | 917-900-1759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 S COLORADO AVE STE 111A
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-513-6588
-----------------------------------------------------
Fax | 917-900-1759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | ME120361
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME120361
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------