Provider Demographics
NPI:1104118686
Name:AGNILA, CONCEPCION LATOZA (MD)
Entity type:Individual
Prefix:DR
First Name:CONCEPCION
Middle Name:LATOZA
Last Name:AGNILA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5003
Mailing Address - Country:US
Mailing Address - Phone:904-450-8090
Mailing Address - Fax:
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-450-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119597208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012348500Medicaid
FL14U8KOtherBCBS
FL14U8KOtherBCBS