Provider Demographics
NPI:1750677282
Name:CARABALLO, MELISSA RICHARDSON (DO)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RICHARDSON
Last Name:CARABALLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:RICHARDSON
Other - Last Name:MILITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4250 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-718-2886
Mailing Address - Fax:850-718-2891
Practice Address - Street 1:3028 4TH ST STE A&B
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2127
Practice Address - Country:US
Practice Address - Phone:850-718-2886
Practice Address - Fax:850-633-5908
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 12572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012137600Medicaid