Provider Demographics
NPI:1114218328
Name:LEAVITT MEDICAL ASSOCAITTES OF FLORIDA INC
Entity Type:Organization
Organization Name:LEAVITT MEDICAL ASSOCAITTES OF FLORIDA INC
Other - Org Name:ADVANCED DERMATOLOGY AND COSMETIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER SERVICE REP
Authorized Official - Prefix:
Authorized Official - First Name:NEFRITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:2600 LAKE LUCIEN DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7233
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:1426 E BLOOMINDALE AVE
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596
Practice Address - Country:US
Practice Address - Phone:888-540-9660
Practice Address - Fax:407-875-0518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98046HMedicare PIN