Healthcare Provider Details

I. General information

NPI: 1609362755
Provider Name (Legal Business Name): MELISSA BLACKBURN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E CENTRAL AVE
WINTER HAVEN FL
33880-3050
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-5000
  • Fax:
Mailing address:
  • Phone: 863-687-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS17882
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: