Basic Information
Provider Information | |||||||||
NPI: | 1417360686 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOLDEN SHORE MEDICAL GROUP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
Address2: |   | ||||||||
City: | SOUTH PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910305801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263462455 | ||||||||
FaxNumber: | 6266393005 | ||||||||
Practice Location | |||||||||
Address1: | 6339 MACK RD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958234655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9165857912 | ||||||||
FaxNumber: | 8774797101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2014 | ||||||||
LastUpdateDate: | 02/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALDERON | ||||||||
AuthorizedOfficialFirstName: | GLORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, AFC | ||||||||
AuthorizedOfficialTelephone: | 6263462455 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | EFFECTIVE 1/5/15 | 05 | CA |   | MEDICAID |