Healthcare Provider Details

I. General information

NPI: 1073885786
Provider Name (Legal Business Name): JOSEPH M MOLINA MD PROFESSIONAL CORPORATION-SOUTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date: 11/05/2013
Reactivation Date: 03/28/2014

III. Provider practice location address

3322 BROADWAY SUITE 200
EVERETT WA
98201-4425
US

IV. Provider business mailing address

200 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 425-249-4922
  • Fax: 877-860-2284
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 StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GLORIA CALDERON
Title or Position: VICE PRESIDENT, CLINIC OPERATIONS
Credential:
Phone: 562-491-7053