=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508002999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OTTO C CONCEPCION M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2009
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15335 SW 288TH ST
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33033-1356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-248-3814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14270 SW 33RD ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-230-9980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME103235
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------