Provider Demographics
NPI:1770524951
Name:CONCEPCION, ROBERTO S (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:S
Last Name:CONCEPCION
Suffix:
Gender:M
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:L-3549
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43301-1814
Practice Address - Country:US
Practice Address - Phone:740-383-7950
Practice Address - Fax:740-375-8164
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049715C208800000X
OH35.049715208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340006973OtherTRAVELERS MEDICARE
1900051OtherUHC
311098079OtherTAX ID #
0647181OtherPALMETTO MEDICARE
353077OtherSUBMITTER NO.
643269OtherAETNA
OH0567686Medicaid
311098079007OtherCIGNA
643269OtherAETNA
340006973OtherTRAVELERS MEDICARE
OH0567686Medicaid