Provider Demographics
NPI:1922379668
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 1:17500 FOOTHILL BLVD
Practice Address - Street 2:#A-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3798
Practice Address - Country:US
Practice Address - Phone:909-428-0170
Practice Address - Fax:877-778-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPPROVED EFF 1/31/12Medicaid
CADU4034-EFF. 3/10/12OtherRAILROAD MEDICARE
CAAPPROVED EFF 1/31/12Medicaid