Provider Demographics
NPI:1669790853
Name:LETOBARONE, MELANIE C (MD)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:C
Last Name:LETOBARONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 S FLORIDA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2101
Mailing Address - Country:US
Mailing Address - Phone:863-209-7004
Mailing Address - Fax:863-274-3542
Practice Address - Street 1:4715 S FLORIDA AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2101
Practice Address - Country:US
Practice Address - Phone:863-209-7004
Practice Address - Fax:863-274-3542
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120044208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012445000Medicaid
FLHV638ZMedicare PIN