Healthcare Provider Details

I. General information

NPI: 1669790853
Provider Name (Legal Business Name): MELANIE C LETOBARONE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 S FLORIDA AVE STE 200
LAKELAND FL
33813-2101
US

IV. Provider business mailing address

4715 S FLORIDA AVE STE 200
LAKELAND FL
33813-2101
US

V. Phone/Fax

Practice location:
  • Phone: 863-209-7004
  • Fax: 863-274-3542
Mailing address:
  • Phone: 863-209-7004
  • Fax: 863-274-3542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME120044
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME120044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: