Healthcare Provider Details

I. General information

NPI: 1487645586
Provider Name (Legal Business Name): LORNE YUDCOVITCH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1756
US

IV. Provider business mailing address

22165 NE FRYER HILL RD
DUNDEE OR
97115-9179
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-2781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2588AT
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2588AT
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2588AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: