Provider Demographics
NPI:1629212519
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 SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER SERVICE
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 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:12600 PEMBROKE RD
Practice Address - Street 2:SUITE 312
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-2544
Practice Address - Country:US
Practice Address - Phone:954-431-7681
Practice Address - Fax:954-431-7682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98046BMedicare PIN