Provider Demographics
NPI:1699836288
Name:STEVENS, GLORIA JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:JANE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GLORIA
Other - Middle Name:JANE
Other - Last Name:LISKANICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
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
CAG058338207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330357267OtherCCN
CA330357267OtherTRI CARE
CA330357267OtherBLUE CROSS
CA330357267OtherHEALTH NET
CA330357267OtherUNITED HEALTH CARE
CA330357267OtherBLUE SHEILD
CA330357267OtherAETNA
CA330357267OtherPACIFICARE
CA8357422Medicaid
CA330357267OtherTRI CARE
CAE48743Medicare UPIN