Basic Information
| Provider Information | |||||||||
| NPI: | 1215203385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA MOLINA | ||||||||
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| OtherOrganizationName: | MOLINA MEDICAL GROUP OF SOUTHERN CA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1714 ST. MICHAELS DRIVE | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056297585 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AFC | ||||||||
| AuthorizedOfficialTelephone: | 5624917053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.