Provider Demographics
NPI:1700044286
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:DIRECTOR, PROVIDER SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:2600 LAKE LUCIEN DR STE 180
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7235
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:1503 BUENOS AIRES BLVD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-6821
Practice Address - Country:US
Practice Address - Phone:352-753-2812
Practice Address - Fax:352-753-5037
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
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256877220Medicaid
FL98046Medicare PIN