Basic Information
Provider Information | |||||||||
NPI: | 1104845767 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ACEVEDO ACOSTA | ||||||||
FirstName: | GILBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 E DIXIE AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347487601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523264031 | ||||||||
FaxNumber: | 3523600257 | ||||||||
Practice Location | |||||||||
Address1: | 801 E DIXIE AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347487601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523264031 | ||||||||
FaxNumber: | 3523600257 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ACN1010 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | PZ074 | 01 | FL | MEDICARE | OTHER | 24610300 | 05 | FL |   | MEDICAID | ACN1010 | 01 | FL | STATE LICENSE | OTHER | JP802 | 01 | FL | MEDICARE | OTHER | BA0911962 | 01 | FL | DEA | OTHER |