Basic Information
| Provider Information | |||||||||
| NPI: | 1942243308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONCEPCION | ||||||||
| FirstName: | NOEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 576649 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953576649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095733333 | ||||||||
| FaxNumber: | 2098440334 | ||||||||
| Practice Location | |||||||||
| Address1: | 6466 BAYVIEW DR | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946053134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092776792 | ||||||||
| FaxNumber: | 2098440334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | G56704 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | M-1488 | GU | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | G56704 | CA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | M-1488 | GU | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | CD069A | 01 | CA | MEDICARE GROUP PTAN | OTHER | ZZZ76734Z | 05 | CA | MEDICAID |