Provider Demographics
NPI:1386221398
Name:CONOVALOFF, JOSEPH LUKE
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LUKE
Last Name:CONOVALOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST ARBOR DRIVE, MAIL CODE 8465
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-8465
Mailing Address - Country:US
Mailing Address - Phone:619-543-6266
Mailing Address - Fax:
Practice Address - Street 1:200 WEST ARBOR DRIVE, MAIL CODE 8465
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8465
Practice Address - Country:US
Practice Address - Phone:619-543-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA7621207R00000X
CAA1811852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine