Healthcare Provider Details

I. General information

NPI: 1518115344
Provider Name (Legal Business Name): MDA MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 03/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N ROSE DR
PLACENTIA CA
92870-3802
US

IV. Provider business mailing address

721 W WHITTIER BLVD SUITE O
LA HABRA CA
90631-3759
US

V. Phone/Fax

Practice location:
  • Phone: 714-993-2000
  • Fax: 714-524-4866
Mailing address:
  • Phone: 714-277-4200
  • Fax: 714-866-4127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA94063
License Number StateCA

VIII. Authorized Official

Name: DR. MICHELLE ELIZABETH HARAKO
Title or Position: PRESIDENT
Credential: MD
Phone: 714-277-4200