Provider Demographics
NPI:1487645586
Name:YUDCOVITCH, LORNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LORNE
Middle Name:
Last Name:YUDCOVITCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22165 NE FRYER HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1756
Practice Address - Country:US
Practice Address - Phone:503-352-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2588AT152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168366Medicaid
300200803OtherBC HMO/FC 65
OR2588ATOtherSTATE OPTOMETRY LICENSE #
5255690001OtherDMERC
831474004OtherBLUE CROSS BLUE SHIELD
OR2588ATOtherSTATE OPTOMETRY LICENSE #
831474004OtherBLUE CROSS BLUE SHIELD