Provider Demographics
NPI:1518300912
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:GOLDEN SHORE MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT, 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:626-346-2455
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:14544 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4214
Practice Address - Country:US
Practice Address - Phone:562-499-6191
Practice Address - Fax:562-499-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2018-02-07
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADU5182-EFF 8/5/13OtherRAILROAD MEDICARE
CAEFF: 10/21/13Medicaid
CACA109020Medicare PIN