Provider Demographics
NPI:1366672610
Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type:Organization
Organization Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Other - Org Name:ADVANCED DERMATOLOGY
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 1:14546 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 407
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5468
Practice Address - Country:US
Practice Address - Phone:904-400-6565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LMG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98046Medicare UPIN