Provider Demographics
NPI:1063842334
Name:JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA
Other - Org Name:MOLINA MEDICAL GROUP OF SOUTHERN CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-499-6191
Mailing Address - Street 1:200 OCEANGATE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:2196 WEST 3500 SOUTH, SUITE C1
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3463
Practice Address - Country:US
Practice Address - Phone:562-499-6191
Practice Address - Fax:562-499-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTEFF. 1/6/14Medicaid
UTU00085971-EFF3/3/14Medicare PIN