Healthcare Provider Details

I. General information

NPI: 1144603796
Provider Name (Legal Business Name): AUDRIS MELITA BOL ROA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 COLUMBIA ST
ORLANDO FL
32806-1101
US

IV. Provider business mailing address

7600 GATEWAY BLVD
NEWARK CA
94560-1159
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-3220
  • Fax: 321-843-3210
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number156068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: