Provider Demographics
NPI:1518115344
Name:MDA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MDA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HARAKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-277-4200
Mailing Address - Street 1:721 W WHITTIER BLVD
Mailing Address - Street 2:SUITE O
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-3759
Mailing Address - Country:US
Mailing Address - Phone:714-277-4200
Mailing Address - Fax:714-866-4127
Practice Address - Street 1:1301 N ROSE DR
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3802
Practice Address - Country:US
Practice Address - Phone:714-993-2000
Practice Address - Fax:714-524-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2009-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94063207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty