MEDICARE: MOLINA HEALTHCARE OF NEW MEXICO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1649782962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOLINA HEALTHCARE OF NEW MEXICO

Provider Business Mailing Address
First Line	:	200 OCEANGATE STE 100
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4317
Country	:	US
Telephone Number	:	888-562-5442
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 TIJERAS AVE NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-3234
Country	:	US
Telephone Number	:	888-562-5441
Fax Number	:

Authorized Official
Title or Position	:	PLAN PRESIDENT-MHNM
Name	:	DANIEL SORRELLS
Credential	:
Telephone Number	:	888-562-5442

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	10/26/2017

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Directions to “MOLINA HEALTHCARE OF NEW MEXICO ” Practice Location

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