Medi-Cal Suspended and Ineligible Provider List: July Update

ADDITIONS:

Physician (Susp A)

Israeli, Alexander V. A94992 Suspended

61-59 Dry Harbor Rd. indefinitely effective

Apt. H-48 3/18/2011

Middle Village, NY

Kachinas, Matthew Jay G79674 Suspended

26732 Crown Valley Pkwy. 00G796740 indefinitely effective

Ste. #541 5/12/2011

Mission Viejo, CA

and

1590 Harbor Cay Ln.

Longboat Key, FL

Levatter, Ross Eli, M.D. G62815 Suspended

2601 E. Roosevelt St. 00G628150 indefinitely effective

Phoenix, AZ XPY205465 12/23/2010

and

2807 H St.

Bakersfield, CA

and

5640 E. Wonderview Rd.

Phoenix, AZ

Seideman, Susan E., M.D. G33438 Suspended

609 W. 6th St. 00G334380 indefinitely effective

San Pedro, CA 00G334381 6/27/2011

and 00G334382

3171 Los Feliz Blvd..

Ste. #306

Los Angeles, CA

and

1037 E. Pacific Coast Hwy.

Wilmington, CA

and

2104 Vanderbilt Ln.

Unit C

Redondo Beach, CA

Simms, Ernest Lee, C28561 Suspended

M.D. Inc. 00C285610 indefinitely effective

22336 Main St. 00C285611 4/19/2011

Hayward, CA 00C285612

and CGP064065

9925 International Blvd. 1275569519

Ste. #11

5900 Shattuck Ave.

Ste. #230

Oakland, CA

and

1002 Central Ave.

Alameda, CA

and

103 Shadow Mountain

Oakland, CA

Psychologist (Susp C)

Berman, Mark Elliot, Ph.D. 9698 Suspended

8530 Wilshire Blvd. PSY096980 indefinitely effective

Ste. #206 PSY096981 5/13/2011

Beverly Hills, CA PF0096980

and 1235144072

44815 Fig Ave.

Ste. B

Lancaster, CA

and

40413 Alabar Dr

Palmdale, CA

Psychiatric Technician (Susp C)

Baynot, Eric Daniel 31232 Suspended

1522 Via Rose indefinitely effective

Paso Robles, CA 8/14/2010

Clinical Social Worker (Susp C)

Rodriguez, Jeannine ASW17034 Suspended

Roseann indefinitely effective

Associate Clinical Social Worker 5/19/2011

11013 Boren Ave.

Loma Linda, CA

Pharmacist (Susp E)

Lang, Johnny Thomas 50571-CA Suspended

5504 Ginger Dr. RPH-0010271 indefinitely effective

Bakersfield, CA -OR 4/20/2011

Mai, Michelle S12319-AZ Suspended

Hoa-Chuong 1999140347-MO indefinitely effective

16051 E, Trevino Dr. 58012-CA 4/20/2011

Fountain Hills, AZ

Voshake, Renee R. 45674 Suspended

1852 Everglade Ave. indefinitely effective

Clovis, CA 4/20/2011

Pharmaceutical Technician (Susp E)

Costere, Randy Alan 44904 Suspended

aka: Randy Allen Costere indefinitely effective

412 Hillcrest Dr. 4/20/2011

Aptos, CA

Dague, Luke D. 53510 Suspended

7098 Agate St. indefinitely effective

Rancho Cucamonga, CA 4/20/2011

Edge, Jaime P. 78753 Suspended

708 Williams Dr. indefinitely effective

Unit #2 4/20/2011

Huntington Beach, CA

Ibarra, Angelina 18088 Suspended

244 Wisteria Dr. indefinitely effective

East Palo Alto, CA 4/20/2011

Manto, Jaynalee 73450 Suspended

Fajilagutan indefinitely effective

aka: Jayna F. Manto 4/20/2011

5737 Everwood Ct.

Richmond, CA

Parks, Jennifer Erin TCH57498 Suspended

1300 Robbins Ct. indefinitely effective

Suisun City, CA 4/20/2011

Tabara, Angelica 63715 Suspended

aka: Angelica Suyat indefinitely effective

Tabara 4/20/2011

416 88th St.

Apt. #7

Daly City, CA

Sick Room Supply (Susp F)

GMS Ventures, Inc. Suspended

GMS Medical Supplies indefinitely effective

1155 N. Vermont Ave. 4/20/2011

Ste. #203

Los Angeles, CA

Acupuncturist (Susp I)

Chung, Hyun Mo 7067 Suspended

902 Stannage Ave. AC0070670 indefinitely effective

Albany, CA 4/20/2011

and

5358 Case Ave.

Apt. #1013

Pleasanton, CA

Chiropractor (Susp J)

Sweet, William DC25936 Suspended

aka: William E. Sweet indefinitely effective

aka: William Edward Sweet 6/14/2011

3908 W. Caldwell Ave.

Ste. B

Visalia, CA

Willard, Teresa Darlene 20842 Suspended

231 E. Mayberry Ave. indefinitely effective

Hemet, CA 1/6/2011

Yoo, Casey K. C., D.C. 19339 Suspended

aka: Casey Kwangchoon DC0193390 indefinitely effective

Yoo 6/13/2011

3545 Wilshire Blvd.

#315

Los Angeles, CA

Medical Transportation (Susp N)

Advanced Medical MTN00871G Suspended

Transport Inc. 1932329018 indefinitely effective

Owner: Yerkanyan, Edgar 6/23/2011

501 S. Fairfax Ave.

Ste. #207

Los Angeles, CA

Clinic (Susp O)

Tahara Center Suspended

Acupuncture & Weight Loss indefinitely effective

4725 1st St. 4/20/2011

Ste. #270

Pleasanton, CA

Occupational Therapist (Susp O)

Clements, Solena Amber OTA 1504 Suspended

Occupational Therapist Assistant indefinitely effective

218 W. Valerio St. 6/14/2011

Apt. B

Santa Barbara, CA

Home Health Aide (Susp P)

Guzman, Robert 147975 Suspended

4040 W. 161st St. indefinitely effective

Lawndale, CA 1/10/2011

Silaen, Uliroma N. 83449 Suspended

7423 Fleming Ave. indefinitely effective

Sacramento, CA 11/9/2010

Registered Nurse (Susp R)

Bertschinger, Merrideth Jo 575974 Suspended

aka: Merrideth Jo Rannow indefinitely effective

1441 Louden Lane 7/2/2010

Imperial Beach, CA

Bolong, Teresita C. 220963 Suspended

28819 Crestridge Rd. indefinitely effective

Rancho Palos Verdes, CA 9/17/2010

Registered Nurse (Susp R) …(continued)

Boyer, Timothy Lee 647230 Suspended

PO Box 1 indefinitely effective

Wynona, OK 8/20/2010

Dusel, Jan Shell 209108 Suspended

aka: Jan Shell indefinitely effective

444 Rosalie Dr. 12/9/2010

Sonoma, CA

Hadley, Heather Shea 671530 Suspended

10497 Steeplechase Dr. indefinitely effective

Gulfport, MS 12/9/2010

Haldin, Marc Charles 627608-CA Suspended

15680 Lake Terrace Dr. RN134568-AZ indefinitely effective

Lake Elsinore, CA 12/7/2010

Krueger, Jeanne Marie 690797 Suspended

4457 Winding River Cir. indefinitely effective

Stockton, CA 9/9/2010

Moreno, Florencio IV 548586 Suspended

aka: Huey Moreno indefinitely effective

9009 Rieti Ln. 6/10/2010

Stockton, CA

Nelson, Margaret Marie 415938 Suspended

aka: Peggy Marie Perini indefinitely effective

aka: Peggy Marie Mellon 9/9/2010

21 S. Peak

Laguna Niguel, CA

O'Connor, Karyn Mary 689235 Suspended

aka: Karen Mary O'Connor indefinitely effective

aka: Karyn Mary O'Conner 8/26/2010

P.O. Box 2114

Upland, CA

Prasad, Catherine 489301 Suspended

Elizabeth indefinitely effective

10841 Fire Island Cir. 6/9/2010

Stockton, CA

Salomon, David IMF48775 Suspended

184 Barrett Rd. indefinitely effective

Riverside, CA 5/19/2011

Tracy, Bridget Lynn 301574 Suspended

1401 S. Grand Ave. indefinitely effective

Los Angeles, CA 6/7/2010

and

624 E. Elder St.

Fallbrook, CA

and

245 Evening Canyon Rd.

Corona Del Mar, CA

Vrban, Johnathan Michael 452385 Suspended

aka: Jon Michael Vrban indefinitely effective

1980 Vallejo St. 10/19/2010

Ninth Floor

San Francisco, CA

Warner, Marion Louise 615639 Suspended

P.O. Box 604 indefinitely effective

Atascadero, CA 9/3/2010

Winter, Kimberly Jeanne 601747 Suspended

5950-B Mission Center Rd. indefinitely effective

San Diego, CA 2/4/2011

Certified Nurse Assistant (Susp R)

Braun, Emy 690346 Suspended

P.O. Box 15 indefinitely effective

Delano, CA 8/24/2010

Certified Nurse Assistant (Susp R) …(continued)

Dollinger, Janet F. 60178 Suspended

601 Ribier Ave. indefinitely effective

Lodi, CA 12/7/2010

Guzman, Robert 188168 Suspended

4040 W. 161st St. indefinitely effective

Lawndale, CA 1/10/2011

Perry, Kimberly Ann 721357 Suspended

aka: Kimberly K. Warner indefinitely effective

aka: Kim Marie Werner 8/25/2010

aka: Kimberly Leanne Warner

aka: Kim Knabe Warner

aka: Kimberly Johnson

2308 Harvard Dr.

Visalia, CA

Silaen, Uliroma N. 338638 Suspended

7423 Fleming Ave. indefinitely effective

Sacramento, CA 11/9/2010

Tapia-Ugarte, 59348 Suspended

Guillermo Diego indefinitely effective

aka: Guillermo Diego Ugarte 6/6/2011

247 E. Bobier Dr.

Vista, CA

and

4405 Maple Dr.

Oceanside, CA

Nurse Anesthetist (Susp R)

Tracy, Bridget Lynn, CRNA 675 Suspended

1401 S. Grand Ave. RN3015740 indefinitely effective

Los Angeles, CA 1649466327 6/7/2010

and

624 E. Elder St.

Fallbrook, CA

and

245 Evening Canyon Rd.

Corona Del Mar, CA

Licensed Vocational Nurse (Susp R)

Betts, Teresa Lynn 190165 Suspended

3405 Erickson St. indefinitely effective

Unit E8 6/24/2010

Gig Harbor, WA

Carter, Adrienne Michelle 193385 Suspended

27537 Stanford Dr. indefinitely effective

Temecula, CA 6/4/2010

Denny, Patricia Dawn 183944 Suspended

6488 Boone Ct. indefinitely effective

Magalia, CA 7/24/2010

Forcier, Elissa Kay 164106 Suspended

12995 Club Dr. indefinitely effective

Redlands, CA 6/11/2010

Hunter, Aaron Andreas 219130 Suspended

1035 Clinton Rd. indefinitely effective

Sacramento, CA 6/3/2010

Isik, Bulent 185400 Suspended

351 Acacia Ave. indefinitely effective

Apt. #25 6/14/2010

Carlsbad, CA

Jordan, Paul Samuel 176650 Suspended

17590 Olinda Rd. indefinitely effective

Anderson, CA 8/15/2010

Leon, Araceli 212460 Suspended

2857 Tuberose Dr. indefinitely effective

San Jacinto, CA 4/20/2011

Licensed Vocational Nurse (Susp R) …(continued)

Lerwill, Jan Dolores 185074 Suspended

8444 Sunrise Ave. indefinitely effective

La Mesa, CA 6/9/2010

Meinhofer, Anna Mari 200151 Suspended

aka: Ana Mari Meinhofer indefinitely effective

205 G St. 4/17/2010

Petaluma, CA

Nurse Midwife (Susp R)

Dusel, Jan Shell 166 Suspended

aka: Jan Shell indefinitely effective

444 Rosalie Dr. 12/9/2010

Sonoma, CA

Nurse Practitioner (Susp R)

Vrban, Johnathan Michael 11632 Suspended

aka: Jon Michael Vrban NP Furnisher indefinitely effective

1980 Vallejo St. 10/19/2010

Ninth Floor

San Francisco, CA

Public Health Nurse (Susp R)

Dusel, Jan Shell 15313 Suspended

aka: Jan Shell indefinitely effective

444 Rosalie Dr. 12/9/2010

Sonoma, CA

Respiratory Care Practitioner (Susp S)

Lucas, Maria Jean 27784 Suspended

40435 N. High Noon Way indefinitely effective

Anthem, AZ 11/12/2010

Simhachalam, John 12640 Suspended

Daniel indefinitely effective

1150 W. Phillips St. 11/25/2010

#134

Ontario, CA

Employees (Susp T)

Beard, Brenda Gail Suspended

aka: Brenda Gail Zirkle indefinitely effective

15833 Fallen Leaf Rd. 6/13/2011

La Puenta, CA

Luna, Andres Ramirez Suspended

Capper indefinitely effective

7355 Bakman Ave. 4/20/2011

Sun Valley, CA

Nieto-Rojas, Margarita Suspended

743 N. Claudina St. indefinitely effective

Apt. #101 6/6/2011

Anaheim, CA

Pongo, Alwyn Ortanez Suspended

19822 Main St. indefinitely effective

Apt. #105 6/6/2011

Carsen, CA

Employees (Susp T) …(continued)

Sadiqr, Ajibola Adekeunle Suspended

aka: Mohhamad Mansuri indefinitely effective

aka: Jibson Sadior 6/6/2011

aka: Agrbola Adekunle Sadiqr

aka: Ajibola Adedeunde Sadiqr

aka: Ajibola Adekunde Sadiqr

aka: Ajibola Adekunle Sadiqr

aka: Adekunle Ajiboias Sadiqr

aka: Bola Sadiqr

aka: Jibson Sadiqr

18930 Sherman Way

Reseda, CA

Sillemon, Anthony Suspended

749 Codington Way indefinitely effective

Modesto, CA 6/23/2011

Thompson, Gary T. Suspended

aka: Gary Timothy Thompson indefinitely effective

133 Goethe St. 6/14/2011

San Francisco, CA

Recipient (Susp T)

Hale, Kathleen Cheryl Suspended

IHSS Recipient/Beneficiary indefinitely effective

aka: Kathleen Hill 4/20/2011

aka: Kathleen C. Williams

aka: Kathy Marzette

aka: Kathleen Cheryl Marzette

2043 N. Orchard Ave.

Apt. A

Fresno, CA

Marshall, Juanita Suspended

7556 El Terraza Dr. indefinitely effective

Sacramento, CA 4/20/2011

Business Owner (Susp T)

Adzhyan, Petros Suspended

Valley Vehicle Registration Services indefinitely effective

7256 Rubio St. 6/27/2011

Van Nuys, CA

Owner / Operator (Susp T)

Palma, Nita Almuete Suspended

aka: Nita Almuete Paddit Palma indefinitely effective

aka: Nita Almuete Paddit 4/20/2011

aka: Nita Almuete Paod Palma

Managed Care Nursing Services

Register #56122-112

FCI Dublin

Federal Correctional Institution

5701 8th Street-Camp Parks

Dublin, CA

In-Home Support Services Provider (Susp U)

Brophy, Chad Suspended

2931 34th Ave. indefinitely effective

Sacramento, CA 4/20/2011

Capers, Renee Suspended

643-1/2 W. 57th St. indefinitely effective

Los Angeles, CA 5/19/2011

Galloway, Patricia Ann Suspended

aka: Patsy Galloway indefinitely effective

217 W. Valencia Ave. 5/19/2011

Fresno, CA

In-Home Support Services Provider (Susp U) …(continued)

Lee, April K. Suspended

aka: Kazoua Lee indefinitely effective

758 S. Adler Ave. 5/19/2011

#201

Fresno, CA

Lee, Mee Suspended

1352 N. Willow Ave. indefinitely effective

Fresno, CA 5/19/2011

Merriweather, Shanteciaa Suspended

4040 Myrtle Ave. indefinitely effective

#3 5/19/2011

North Highlands, CA

Morales, Jessica Stephanie Suspended

Camille indefinitely effective

aka: Jessica Stephanie 5/19/2011

Camille Stafford

643 N. Burgan Ave.

Fresno, CA

Ortiz, Josefina Suspended

aka: Josephine Ortiz indefinitely effective

4350 E. Harvard Ave. 5/19/2011

Fresno, CA

Smith, Jimmie Lee Suspended

aka: Jimmy Lee Smith indefinitely effective

2330 S. Tupman Ave. 4/20/2011

Fresno, CA

Sok, Samat Suspended

aka: Somat Kim indefinitely effective

aka: Samat Sok Kim 4/20/2011

2716 Antonio Ave.

Clovis, CA

Thomas, George Edward Jr. Suspended

CDCR #AG1944 indefinitely effective

c/o Wasco State Prison-Reception Ctr. 5/19/2011

D-7108U

P.O. Box 7700

Wasco, CA

Timmons, Shameka Marie Suspended

4801 Scarborough Way indefinitely effective

Sacramento, CA 4/20/2011

Vanderschuere, Richard Suspended

Anthony, Sr. indefinitely effective

SID #5863728 4/20/2011

Mill Creek Correctional Facility

4005 Aumsville Hwy. S.E.

Salem, OR

Wince, Donte Tramel Suspended

9924 Flora Vista St. indefinitely effective

#15 5/19/2011

Bell Flower, CA

REINSTATEMENTS: (REMOVED FROM LIST)

Chiropractor (Susp J)

DeMatteo, Thomas N. 20950 Suspended (removed from pg. 8)

2418 Gage Ave. DC0209500 indefinitely effective

Roseville, CA 6/6/2011

and

1273 W. Central Ave.

Brea, CA

Licensed Vocational Nurse (Susp R)

Santos, Orland VN185572 Suspended (removed from pg. 160)

1125 N. Edgemont St. 221865 indefinitely effective

Los Angeles, CA RN712980 5/25/2011

and

4124 Eagle Rock

Apt. #212

Los Angeles, CA