Provider Demographics
NPI:1942234935
Name:BROUGH-STEVENSON, GLORIA I (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:I
Last Name:BROUGH-STEVENSON
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:PO BOX 11259
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1259
Mailing Address - Country:US
Mailing Address - Phone:866-675-9441
Mailing Address - Fax:
Practice Address - Street 1:2755 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6800
Practice Address - Country:US
Practice Address - Phone:559-324-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38221207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G382210Medicaid
CA00G382210Medicare PIN
D33311Medicare UPIN
CA00G382210Medicaid