Medi-Cal Suspended and Ineligible Provider List: September Update

Medi-Cal Suspended and Ineligible Provider List: September Update

ADDITIONS:

Physician (Susp A)

Atiga, Rolando L., M.D.00A251660Suspended

841 Wick Ln.00A251661indefinitely effective

Glendora, CA6/17/2010

and

408 W. Baseline Rd.

Glendora, CA

Edwards, Beverly52231-CASuspended

820 Clover Hill Ln.01026336A-INindefinitely effective

Cedar Hill, TX2/2/2010

Freesemann, JeffreyG83122Suspended

Mark, M.D.00G831220indefinitely effective

1524 27th St.8/11/2020

Ste. #201

Bakersfield, CA

and

P.O. Box 20785

Bakersfield, CA

Healy, Daniel James,00G453410Suspended

M.D.1205860525indefinitely effective

1755 E. Huntington Dr.6/17/2010

Ste. #104

Duarte, CA

Paskewitz, Mark ThomasG75246Suspended

P.O. Box 41900G752460indefinitely effective

Pasadena, CA00G7524611/29/2010

Patel, Vikramkumar D.A39124Suspended

2106 Twin Oaks Blvd.indefinitely effective

Kemah, TX4/28/2010

Petrakis, Steven JohnGFE 35401Suspended

1703 Escalante S.W.indefinitely effective

Albuquerque, NM4/26/2010

Whittemore, DexterC32389Suspended

Delmont, Jr.indefinitely effective

110 Bank St. S.E.4/15/2010

#705

Minneapolis, MN

Yusim, Jeffrey DavidA45129Suspended

755 E. Valley Pkwy.1659355907indefinitely effective

Escondido, CA00A4512903/27/2010

and

840 Townsite Dr.

Vista, CA

Psychologist (susp C)

Bunce, Jon Stanley10265Suspended

118 Park Ave.indefinitely effective

Merced, CA7/21/2010

Pharmacist(susp E)

Byrd, Patricia Katherine46869Suspended

A2-193indefinitely effective

2360 Mendocino Ave.6/17/2010

Ste. A2

Santa Rosa, CA

Pharmaceutical Technician(susp E)

Kenison, Cassaundra44918Suspended

Alanaindefinitely effective

1030 Cardoso Ln.5/20/2010

Newcastle, CA

Parish, Sandra Dee60425Suspended

7 W. Magnolia St.indefinitely effective

#76/17/2010

Stockton, CA

Sick Room Supply (susp F)

Arakelyan, KarenSuspended

14235 Hamlin St.indefinitely effective

Van Nuys, CA6/17/2010

Dentist (susp G)

Hakimpour, RezaB43167-01Suspended

2390 Hecate Ct.indefinitely effective

San Jose, CA8/25/2010

Audiologist (susp H)

Nahmouli, Nina366Suspended

3525 Pacific Coast Hwy.AU0036600indefinitely effective

Torrance, CAAU00366018/11/2010

and

2265 S. Beverly Glen

Blvd.

Ste. #103

Los Angeles, CA

Acupuncturist (susp I)

Jeon, Kyoung Seok8838Suspended

110 Hilltop Dr.indefinitely effective

Apt. #1275/20/2010

Redding, CA

Song, Kisoo7495Suspended

2316 Artesia Blvd.1770662181indefinitely effective

Apt. E6/17/2010

Redondo Beach, CA

Chiropractor (susp J)

Pham, James28720Suspended

aka: Duong Truong Phamindefinitely effective

8060 E. Florence Ave.3/8/2010

#209

Downey, CA

Shadjareh, Mir JafarDC22848Suspended

aka: Jeff Shadjarehindefinitely effective

62 Corporate Park8/1/2010

#145

Irvine, CA

Home Health Aide (susp P)

Chatman, Rhonda158408Suspended

24261 Via Vargas Dr.indefinitely effective

Moreno Valley, CA3/16/2010

Ferguson-Wall,118989Suspended

Caprice Marieindefinitely effective

P.O. Box 844/20/2010

Glencoe, CA

Home Health Aide (susp P) …(continued)

Monge, Maria C.161378Suspended

P.O. Box 401094indefinitely effective

San Francisco, CA3/15/2010

Riccitelli, Linda101772Suspended

695 Carla Ave.indefinitely effective

Chula Vista, CA2/17/2010

Santiago, Isabel Cristina158505Suspended

20268 Road 31indefinitely effective

Madera, CA12/1/2009

Williams, De Shawn167323Suspended

5950 S. Main St.indefinitely effective

#3133/23/2010

Los Angeles, CA

Optometrist (susp Q)

Kim, Martin SungSD0111620Suspended

aka: Martin Sung KimGSD004770indefinitely effective

Optometry Inc.8/25/2010

aka: Fashion Eyeland

Optometry

17188 Colima Rd.

Ste. D

Hacienda Heights, CA

Registered Nurse (susp R)

Bauer, Krystal Ann502554-CASuspended

2760 Tech Dr.PN33809-IOindefinitely effective

Unit #107RN089513-IO2/25/2010

Bettendorf, IA

Blaze, Deborah544432Suspended

Kathleenindefinitely effective

528 Peach Dr.6/17/2010

Chowchilla, CA

Buettner, Melanie Lynn625628Suspended

2495 Mockingbird Ln.indefinitely effective

N.W.1/20/2010

Hartselle, AL

Crews, Matthew Lee589514-CASuspended

925 River Rd.14-086704-indefinitely effective

Clarksburg, MA 061-KS2/22/2010

Erokan, Sandra Jo358050Suspended

1792 Claycord Ave.indefinitely effective

Concord, CA4/1/2010

Frazier, Cathey Gay475558Suspended

740 Main St.indefinitely effective

Yuba City, CA2/20/2010

Griffin, John Joseph475739Suspended

6575 Paseo Fronteraindefinitely effective

Apt. F1/25/2010

Carlsbad, CA

Holliday, Carol Elizabeth475931Suspended

109 Miramonte Dr.indefinitely effective

Moraga, CA2/17/2010

Judd, Agnes L.304814Suspended

aka: Agnes L. Howardindefinitely effective

1175 E. La Moore Rd.2/22/2010

Apt. #10

San Marcos, CA

Macabeo, Thelma C.171365Suspended

1742 Preuss Rd.indefinitely effective

Los Angeles, CA4/1/2010

Registered Nurse (susp R) …(continued)

Martin, Amy Michele645511Suspended

207 Irene St.indefinitely effective

Bakersfield, CA2/8/2010

Matijevich, Ken George597315Suspended

604 Olive Ave.indefinitely effective

Huntington Beach, CA3/29/2010

McMordie, Colleen535423Suspended

Michele indefinitely effective

1211 S. White Rd.1/29/2010

San Jose, CA

Morrison, Leslie Berard452645Suspended

aka: Leslie Berardindefinitely effective

1190 Ninth St.1/20/2010

Alameda, CA

Norman, Thomas Charles70453Suspended

4200 The Woods Dr.indefinitely effective

#9032/6/2010

San Jose, CA

Noyes, Karen Christina703156Suspended

24 Tyler St.indefinitely effective

Novato, CA12/30/2009

Puhr, Rebecca Joanne599025Suspended

15800 Lasselle St.indefinitely effective

Apt. N2/8/2010

Moreno Valley, CA

Rede, Marc Williams604274Suspended

100 Dolores St.indefinitely effective

#2202/6/2010

Carmel, CA

and

24835 A Torres St.

Carmel, CA

Rucker, Shelley Grace640085Suspended

110 Gold Course Dr.indefinitely effective

Apt. #3041/28/2010

Rohnert Park, CA

Thompkins, Ursula593615Suspended

Memeta indefinitely effective

aka: Ursula Meleta4/12/2010

Arellano Grafeman

Thompkins

8 Moselle Ct.

O'Fallon, MO

Tonsberg, Wayne263213Suspended

aka: Reldon Wayneindefinitely effective

Tonsberg4/1/2010

aka: Reldon W. Tonsberg

220 Sky Oaks Dr.

Angwin, CA

Vercio, Michelle Linda690849Suspended

1754 42nd St. S.W.indefinitely effective

Naples, FL3/22/2010

Wagoner, Cathleen122164-AZSuspended

Cadman617469-CAindefinitely effective

2103 Harrison Ave. N.W.00142442-WA6/17/2010

#23431528202741

Olympia, WA

Wall, VirginiaFrances257146Suspended

Dittmyerindefinitely effective

aka: Virginia Wall4/15/2010

aka: Virginia Dittmyer

105 Lanark St.

Sun Valley, CA

Registered Nurse (susp R) …(continued)

Wilkes, Jennifer365156Suspended

aka: Jenniferindefinitely effective

Wilkes-Needling1/27/2010

2588 CR N.W. 1070

Talco, TX75487

Certified Nurse Assistant (susp R)

Chatman, Rhonda516026Suspended

24261 Via Vargas Dr.indefinitely effective

Moreno Valley, CA3/16/2010

Ferguson-Wall,401372Suspended

Caprice Marieindefinitely effective

P.O. Box 844/20/2010

Glencoe, CA

Godoy, Veronica679018Suspended

9398 Lembert Dome Cir.indefinitely effective

Stockton, CA8/13/2009

Holmes, Aisha164468Suspended

24213 Fawn St.indefinitely effective

Moreno Valley, CA3/16/2010

Meza, Elliott N.676728Suspended

336 S. Steckel Dr.indefinitely effective

#34/21/2010

Santa Paula, CA

Monge, Maria C.525784Suspended

P.O. Box 401094indefinitely effective

San Francisco, CA3/15/2010

Riccitelli, Linda384342Suspended

695 Carla Ave.indefinitely effective

Chula Vista, CA2/17/2010

Santana, Maria598562Suspended

3641 Maxson Rd.indefinitely effective

El Monte, CA6/17/2010

Santiago, Isabel Cristina514187Suspended

20268 Road 31indefinitely effective

Madera, CA12/1/2009

Tugung, Kauzer718965Suspended

1111 W. Benwood St.indefinitely effective

Covina, CA3/16/2010

Williams, De Shawn545392Suspended

5950 S. Main St.indefinitely effective

#3133/23/2010

Los Angeles, CA

Williams, Faatali496286Suspended

aka: Faatali Pateaindefinitely effective

43868 Emile Zola St.3/18/2010

Lancaster, CA

Licensed Vocational Nurse (susp R)

Durrant, Carrie Lynn177241Suspended

aka: Carrie Lynn Lacellaindefinitely effective

43786 Nathan Dr.1/16/2010

Hemet, CA

Nelson, Pamela Renee133430Suspended

4207 S. Van Ness Ave.indefinitely effective

Los Angeles, CA8/11/2010

Soldano, Jena Dianenot providedSuspended

1817 Strauss Ln.indefinitely effective

Redding, CA8/2/2010

Licensed Psychiatric Nurse (susp R)

Morrison, Leslie Berard372Suspended

aka: Leslie Berardindefinitely effective

1190 Ninth St.1/20/2010

Alameda, CA

Public Health Nurse (susp R)

Macabeo, Thelma C.11605Suspended

1742 Preuss Rd.indefinitely effective

Los Angeles, CA4/1/2010

Respiratory Care Practitioner (susp S)

Armenta, Maximo27493Suspended

7040 San Luis St.indefinitely effective

Paramount, CA4/24/2010

Bell, Thomas Milton1915Suspended

1246 Baxter Pl.indefinitely effective

Las Vegas, NV1/14/2010

Green, Keturah Charmel20709Suspended

965 Rohwer Ct.indefinitely effective

Dixon, CA1/28/2010

Partridge, Charles Edward4301Suspended

15023 Mystic St.indefinitely effective

Whittier, CA3/27/2010

Scott, Kamtra Tamika20518Suspended

300 Lloyd St.indefinitely effective

Bakersfield, CA1/2/2010

Steen, Vialva Patrice24024Suspended

P.O. Box 642042indefinitely effective

Los Angeles, CA1/29/2010

Employee (susp T)

Crews, Mark JohnSuspended

937 Vanderbilt Wayindefinitely effective

Sacramento, CA8/25/2010

Gonzales, Patricia AnnSuspended

1033 Norma Ct.indefinitely effective

Chula Vista, CA6/17/2010

Jeannotte, Carol JeanSuspended

325 Nolan Wayindefinitely effective

Chula Vista, CA6/17/2010

Business Owner (susp T)

Belmarez, Juan ManuelMTN00360FSuspended

Bel Mar Medical1477696011indefinitely effective

Transportation8/15/2010

480 Aurora Dr.

Apt. #107

El Centro, CA

Kim, Martin SungSD0111620Suspended

aka: Martin Sung KimGSD004770indefinitely effective

Optometry Inc.8/25/2010

aka: Fashion Eyeland

Optometry

17188 Colima Rd.

Ste. D

Hacienda Heights, CA

Owner/Operator (susp T)

Arakelyan, KarenSuspended

Durable Medical Equipmentindefinitely effective

14235 Hamlin St.6/17/2010

Van Nuys, CA

Gabriyleyan, MelkonSuspended

Sick Room Supplyindefinitely effective

CI Taft / Correctional6/17/2010

Institution

P.O. Box 7001

Taft, CA

In-Home Support Services Provider (susp U)

Antone, GeorgetaSuspended

8109 Cottonridge Cir.indefinitely effective

Sacramento, CA6/17/2010

Aquirre, ElizabethSuspended

aka: Elizabeth Sanchezindefinitely effective

2415 E. Lewis6/17/2010

Fresno, CA

Bookman, Arnold RaySuspended

aka: Arnold Turnerindefinitely effective

aka: Randy Duran6/17/2010

aka: William Mosley

6641 Harms Way

Sacramento, CA

Coronado, FilomenaSuspended

Conceicaoindefinitely effective

1310 F St.6/17/2010

Livingston, CA

Daniels, Shelia MarieSuspended

5941 Bamford Dr.indefinitely effective

Sacramento, CA6/17/2010

Edwards, Kenneth Ray Jr.Suspended

4401 Oakhollow Dr.indefinitely effective

#116/17/2010

Sacramento, CA

Horrigan, Kathryn MargaretSuspended

4982 Harrison St.indefinitely effective

North Highlands, CA6/17/2010

Johnson, TahirahSuspended

1665 N. Marksindefinitely effective

#1196/17/2010

Fresno, CA

Martinez, SocorroSuspended

3482 26th Ave. (rear)indefinitely effective

Sacramento, CA5/20/2010

Narlock, Francisca MallariSuspended

447 Ariel Ct.indefinitely effective

San Jose, CA6/17/2010

Onate, BeverlySuspended

1549 Barberry Pl.indefinitely effective

Chula Vista, CA5/20/2010

Ramer, Debra JoyceSuspended

5754 W. Sampleindefinitely effective

Fresno, CA5/20/2010