Provider Demographics
NPI:1902052590
Name:MOLINA, LUIS ALFONSO (OD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALFONSO
Last Name:MOLINA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-232-1360
Practice Address - Street 1:1809 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2113
Practice Address - Country:US
Practice Address - Phone:619-515-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13595 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW5352OtherCORPORATE UPIN