Healthcare Provider Details

I. General information

NPI: 1245391820
Provider Name (Legal Business Name): RONALD DEMETRI LISKANICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 W FOOTHILL BLVD STE B
UPLAND CA
91786
US

IV. Provider business mailing address

954 W FOOTHILL BLVD STE B
UPLAND CA
91786-3782
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-7500
  • Fax: 909-946-1133
Mailing address:
  • Phone: 909-949-7500
  • Fax: 909-946-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number20A4952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: