Provider Demographics
NPI:1801177944
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:<UNAVAIL>
Other - Org Type:
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:562-499-6191
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:1714 SAINT MICHAELS DR
Practice Address - Street 2:#1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7617
Practice Address - Country:US
Practice Address - Phone:505-490-4042
Practice Address - Fax:877-846-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72035005Medicaid
NM72035005Medicaid