Healthcare Provider Details

I. General information

NPI: 1881919801
Provider Name (Legal Business Name): LYDIA LIU TCHORBADJIYSKI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5809 WASHINGTON ST
MORTON GROVE IL
60053-3376
US

IV. Provider business mailing address

5809 WASHINGTON ST
MORTON GROVE IL
60053-3376
US

V. Phone/Fax

Practice location:
  • Phone: 847-867-7051
  • Fax:
Mailing address:
  • Phone: 847-867-7051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010314
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: