Healthcare Provider Details

I. General information

NPI: 1215203385
Provider Name (Legal Business Name): JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA MOLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 ST. MICHAELS DRIVE SUITE #1
SANTA FE NM
87505-6059
US

IV. Provider business mailing address

100 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-7585
  • Fax: 562-499-6171
Mailing address:
  • Phone: 562-499-6191
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GLORIA CALDERON
Title or Position: PRESIDENT AFC
Credential:
Phone: 562-491-7053