Provider Demographics
NPI:1760856413
Name:ADVANCED DERMATOLOGY OF MARYLAND PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF MARYLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
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:407-650-3455
Practice Address - Street 1:2401 RESEARCH BLVD STE 260
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3261
Practice Address - Country:US
Practice Address - Phone:301-990-6565
Practice Address - Fax:301-990-8525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8025029Medicaid
DC545705Medicare PIN