Medi-Cal Suspended and Ineligible Provider List: August Update

ADDITIONS:

Osteopath (susp A)

Stever, Jennifer L. 20A10348 Suspended

15107 Vanowen St. indefinitely effective

Van Nuys, CA 12/3/2012

and

12722 Riverside Dr.

Unit #502

Valley Village, CA

Physician (susp A)

Diaz, Julio G. A36932 Suspended

aka: Otero Julio Gabriel 00A369320 indefinitely effective

Diaz 1801880638 6/19/2013

510 N. Milpas St.

Santa Barbara, CA

Fenderson, Keith Arlyn G4227 Suspended

aka: Keith A. Fenderson 00G422770 indefinitely effective

5451 Walnut Ave. 1902824873 5/27/2013

Chino, CA

and

350 Meadow Gate Rd.

Meadow Vista, CA

Gracia-Olea, Edgardo A33843 Suspended

480 4th Ave. 00A338430 indefinitely effective

Ste. #514 and #404 00A338431 6/5/2013

Chula Vista, CA 1902869597

and

9888 Genesee Ave.

Ste. LJ110

La Jolla, CA

Hohag, David Earl G29744 Suspended

aka: David E. Hohag 00G297440 indefinitely effective

1150 Goodwin Rd. 5/23/13

Lone Pine, CA

and

P.O. Box 1783

Bishop, CA

Holmes, Richard J. A28516 Suspended

500 E. Olive Ave. 00A285160 indefinitely effective

Ste. #430 00A285161 4/23/2013

Burbank, CA 020A24660

and

82-013 Doctor Carreon

Blvd.

Indio, CA

and

2 Santo Domingo Dr.

Rancho Mirage, CA

and

91275 66th Ave.

Mecca, CA

Johnson, Kenneth Delford G26947 Suspended

aka: Kenneth D. Johnson 00G269470 indefinitely effective

701 E. 28th St. 6/12/2013

Ste. #113

Long Beach, CA

and

1506 Bridgeview Dr.

San Diego, CA

Kilgore, Byron William C31188 Suspended

aka: Byron W. Kilgore 00C311880 indefinitely effective

3020 Fillmore St. 5/28/2013

San Francisco, CA

Physician (susp A) … (continued)

McEldoon, Wesley A. C42996 Suspended

6060 N. Paramount Blvd. 00C429960 indefinitely effective

Long Beach, CA 6/21/2013

and

3315 Falcon Ave.

Signal Hill, CA

San Agustin, Winston A39652 Suspended

aka: Winston C. CGP046150 indefinitely effective

Sanagustin 00A396520 6/19/2013

aka: Winston Camacho 18615734353

Sanagustin

500 N. Garfield Ave.

Ste. #102

Monterey Park, CA

and

850 S. Atlantic Blvd.

Ste. #101

Monterey Park, CA

Song, Jong E. A34264 Suspended

24907 Sunnymead Blvd. 00A342640 indefinitely effective

Ste. E 1437169950 5/29/2013

Moreno Valley, CA

Wijegoonaratna, Sri J. A100580 Suspended

M.D. 1457534984 indefinitely effective

aka: Sri Jayantha 7/9/2013

Wijegunaratne

aka: Sri Jayantha

Wijegoonaratna

1120 W. Warner Ave.

Ste. A

Santa Ana, CA

and

820 S. Cottontail Ln.

Anaheim Hills, CA

Sick Room Supply (susp F)

Fendih Medical Suspended

Supplies, Inc. indefinitely effective

Owner: Onyeabor, Godwin 7/9/2013

416 N. H St.

Ste. #5

San Bernadino, CA

Dentist (susp G)

Padgett, James R. Jr. 30735 Suspended

626 E. High Ave. B30735 indefinitely effective

Redlands, CA D30735 7/9/2013

and

Loma Linda University

School of Dentistry

11092 Anderson St.

Loma Linda, CA

Acupuncturist (susp I)

Kim, Beau B. AC5000 Suspended

24208 Crenshaw Blvd. AC0050000 indefinitely effective

Torrance, CA 2/22/2013

and

2849 W. Olympic Blvd.

Los Angeles, CA

Licensed Vocational Nurse (susp R)

Smith, Rebecca Lean not provided Suspended

101 W. Nelson Rd. indefinitely effective

Monroe, LA 7/31/2013

Registered Nurse (susp R)

Lombard, Diane Gustin 766307 Suspended

2381 Villaret Dr. indefinitely effective

Huntsville, AL 4/11/2013

Razo, Alejandro Lopez 319138 Suspended

7042 Balcom Ave. indefinitely effective

Reseda, CA 2/25/2013

Roederer, Patricia 546263 Suspended

P.O. Box 231 indefinitely effective

Brentwood, CA 4/11/2013

Steigert, Andrew Douglas 766039 Suspended

604 Cherry Ave. indefinitely effective

Apt. #302 4/11/2013

Long Beach, CA

Business Owner (susp T)

Onyeabor, Godwin Suspended

Fendih Medical Supplies, Inc. indefinitely effective

416 N. H St. 7/9/2013

Ste. #5

San Bernardino, CA

Corporation (susp T)

Onyeabor, Godwin Suspended

Fendih Medical Supplies, Inc. indefinitely effective

416 N. H St. 7/9/2013

Ste. #5

San Bernardino, CA

Employees (susp T)

Jacobo, Ana Erika Suspended

aka: Erika Jacobo-Pickett indefinitely effective

4429 Highland Ave. 7/9/2013

416 N. H Street

Apt. #5

San Diego, CA

REINSTATEMENTS:

Physician (susp A)

Grier, Barnett John, A23617 6/19/2013 (removed from pg. 35)

Wesley, M.D. 00A236170

aka: Grier, Barnett J.W.

Jr., M.D.

908 S. Central Ave.

Glendale, CA

and

2500 Wilshire Blvd.

Los Angeles, CA

Hyman, Mark Howard G55008 6/19/2013 (removed from pg. 41)

10780 Santa Monica Blvd.

Ste. #408

Los Angeles, CA

Kunihira, Dale Y. 00G591370 10/30/1996 (removed from pg. 49)

2618 Flint Way

Unit #252

San Bernadino, CA

Registered Nurse (susp R)

Tamayo, Ricky M. 556136 9/27/2010 (removed from pg. 115)

1972 Roos Ave.

El Centro, CA

Van Cleave, Steven 269619 6/10/2013 (removed from pg. 120)

Thomas

25271 Arion Way

Mission Viejo, CA