Provider Demographics
NPI:1194765750
Name:CONCEPCION, LUIS VICENTE (DO)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:VICENTE
Last Name:CONCEPCION
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16555 NW 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6583
Mailing Address - Country:US
Mailing Address - Phone:786-466-1736
Mailing Address - Fax:
Practice Address - Street 1:16555 NW 25TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33054-6583
Practice Address - Country:US
Practice Address - Phone:786-466-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254606000Medicaid
FLG90254Medicare UPIN
FL254606000Medicaid