Provider Demographics
NPI:1538608658
Name:KONJKAVFARD, EYESUN (DC)
Entity type:Individual
Prefix:DR
First Name:EYESUN
Middle Name:
Last Name:KONJKAVFARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 JAKE LN APT 14319
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3023
Mailing Address - Country:US
Mailing Address - Phone:619-639-5095
Mailing Address - Fax:
Practice Address - Street 1:15817 BERNARDO CENTER DR STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-2322
Practice Address - Country:US
Practice Address - Phone:858-674-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor