Basic Information
| Provider Information | |||||||||
| NPI: | 1558633255 | ||||||||
| 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: | 790 E FOOTHILL BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095467135 | ||||||||
| FaxNumber: | 8777789467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2012 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CLINIC OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6263462455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | APPROVED EFF: 2/1/12 | 01 | CA | MEDI-CAL | OTHER | DU4034-EFF. 3/5/12 | 01 | CA | RAILROAD MEDICARE | OTHER |