Healthcare Provider Details

I. General information

NPI: 1902192438
Provider Name (Legal Business Name): MELVIN EMEKA OMODON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-7000
  • Fax: 866-264-8519
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036146488
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25IA12313800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number4301099187
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME140585
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number269481
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036146488
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: