Basic Information
| Provider Information | |||||||||
| NPI: | 1780005140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA | ||||||||
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| OtherOrganizationName: | MOLINA MEDICAL GROUP OF SOUTHERN CALIFORNIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840977703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2014 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CLINIC OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5624996191 | ||||||||
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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 | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | EFF. 3/3/14 | 05 | UT | MEDICAID |