Provider Demographics
NPI:1245391820
Name:LISKANICH, RONALD DEMETRI (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DEMETRI
Last Name:LISKANICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 W FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3782
Mailing Address - Country:US
Mailing Address - Phone:909-949-7500
Mailing Address - Fax:909-946-1133
Practice Address - Street 1:954 W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-949-7500
Practice Address - Fax:909-946-1133
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4952207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX49520Medicaid
CA020A49520OtherBLUE SHIELD
CA020A49520Medicare ID - Type Unspecified
CA00AX49520Medicaid