Provider Demographics
NPI:1508801028
Name:MATKOVICH, LYDIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:MATKOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23600 TELO AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4035
Mailing Address - Country:US
Mailing Address - Phone:310-626-8055
Mailing Address - Fax:310-626-8058
Practice Address - Street 1:23600 TELO AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4035
Practice Address - Country:US
Practice Address - Phone:310-626-8055
Practice Address - Fax:310-626-8058
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80774207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G807740OtherBLUE SHIELD
CA00G807740Medicaid
CAP00286193OtherRAILROAD MEDICARE
CA00G807741Medicaid
CA00G807740OtherBLUE SHIELD
CA00G807740Medicaid