Basic Information
| Provider Information | |||||||||
| NPI: | 1508279779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN SHORE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 7777 SUNRISE BLVD | ||||||||
| Address2: | SUITE 2500 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956102300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167222227 | ||||||||
| FaxNumber: | 8778605422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP- CLINIC OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6263462455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 1/5/2015 | 05 | CA | MEDICAID |