Healthcare Provider Details

I. General information

NPI: 1508801028
Provider Name (Legal Business Name): LYDIA MATKOVICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23600 TELO AVE SUITE 210
TORRANCE CA
90505-4035
US

IV. Provider business mailing address

23600 TELO AVE SUITE 210
TORRANCE CA
90505-4035
US

V. Phone/Fax

Practice location:
  • Phone: 310-626-8055
  • Fax: 310-626-8058
Mailing address:
  • Phone: 310-626-8055
  • Fax: 310-626-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG80774
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberG80774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: