Provider Demographics
NPI:1790914992
Name:PODBEREZIN, LYUDMILA P (OD)
Entity Type:Individual
Prefix:DR
First Name:LYUDMILA
Middle Name:P
Last Name:PODBEREZIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2455
Mailing Address - Country:US
Mailing Address - Phone:847-763-0600
Mailing Address - Fax:847-763-0660
Practice Address - Street 1:3455 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2455
Practice Address - Country:US
Practice Address - Phone:847-763-0600
Practice Address - Fax:847-763-0660
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2013-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010277Medicaid