Provider Demographics
NPI:1043581119
Name:CONCEPCION, PAUL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:CONCEPCION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAUL
Other - Middle Name:
Other - Last Name:VILLASUSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:129 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1265
Mailing Address - Country:US
Mailing Address - Phone:630-924-8112
Mailing Address - Fax:630-924-0651
Practice Address - Street 1:129 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1265
Practice Address - Country:US
Practice Address - Phone:630-924-8112
Practice Address - Fax:630-924-0651
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-22
Last Update Date:2012-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036034522174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036034522OtherILLINOIS LICENSE