Basic Information
Provider Information | |||||||||
NPI: | 1700158417 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOLINA MEDICAL GROUP OF SOUTHERN CALIFORNIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 OCEANGATE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908024317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624996191 | ||||||||
FaxNumber: | 5624996171 | ||||||||
Practice Location | |||||||||
Address1: | 15 SW EVERETT MALL WAY | ||||||||
Address2: | SUITE A | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982042715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253486727 | ||||||||
FaxNumber: | 8778602991 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2012 | ||||||||
LastUpdateDate: | 06/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALDERON | ||||||||
AuthorizedOfficialFirstName: | GLORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT-CLINIC OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 5624917053 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207Q00000X |   | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | APPROVED/PROVIDERONE | 05 | CA |   | MEDICAID |