MEDICARE: JOSEPH LUKE CONOVALOFF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	7621	CA
3	2084N0400X	Neurology Physician	A181185	CA

General Provider Information

NPI Number	:	1386221398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH LUKE CONOVALOFF

Provider Business Mailing Address
First Line	:	200 WEST ARBOR DRIVE, MAIL CODE 8465
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-8465
Country	:	US
Telephone Number	:	619-543-6266
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WEST ARBOR DRIVE, MAIL CODE 8465
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-8465
Country	:	US
Telephone Number	:	619-543-6266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	12/29/2022

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