1518300912 NPI number — JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA

Table of content: (NPI 1518300912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518300912 NPI number — JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH M MOLINA MD PROFESSIONAL CORPORATION - SOUTHERN CALIFORNIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GOLDEN SHORE MEDICAL GROUP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518300912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 FAIR OAKS AVE STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-346-2455
Provider Business Mailing Address Fax Number:
626-639-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14544 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-4214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-499-6191
Provider Business Practice Location Address Fax Number:
562-499-6191
Provider Enumeration Date:
04/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CALDERON
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT, CLINIC OPERATIONS
Authorized Official Telephone Number:
626-346-2455

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DU5182-EFF 8/5/13 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EFF: 10/21/13 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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