Basic Information
Provider Information | |||||||||
NPI: | 1841305075 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOLINA HEALTHCARE OF CALIFORNIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 OCEANGATE STE 100 | ||||||||
Address2: | MOLINA MEDICAL CENTERS | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908024317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624996191 | ||||||||
FaxNumber: | 5624996171 | ||||||||
Practice Location | |||||||||
Address1: | 3234 MARYSVILLE BLVD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958151411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166461200 | ||||||||
FaxNumber: | 9166463385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 01/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALDERON | ||||||||
AuthorizedOfficialFirstName: | GLORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP CLINIC OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8885625442 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GR004265H | 05 | CA |   | MEDICAID |