Healthcare Provider Details

I. General information

NPI: 1144421546
Provider Name (Legal Business Name): MANUEL ALBERTO MOLINA-VEGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 LAKELAND HILLS BLVD
LAKELAND FL
33805-1965
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD MEDICAL STAFF OFFICE
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-603-6565
  • Fax: 863-904-1961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME101729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: