Provider Demographics
NPI:1528226081
Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type:Organization
Organization Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Other - Org Name:ADVANCED DERMATOLOGY AND COSMETIC SUR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROV SER 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 1:1300 NW 17TH AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2578
Practice Address - Country:US
Practice Address - Phone:561-819-0957
Practice Address - Fax:561-549-0173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-30
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256877213Medicaid
FL98046BMedicare PIN