Basic Information
| Provider Information | |||||||||
| NPI: | 1285690362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONOVALOFF | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057514664 | ||||||||
| FaxNumber: | 4057494561 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 TORRANCE BLVD | ||||||||
| Address2: | EM DEPT | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105407676 | ||||||||
| FaxNumber: | 4057494561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | G31992 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00107714 | 01 | CA | RR MEDICARE | OTHER | 00G319920 | 05 | CA | MEDICAID |