Provider Demographics
NPI:1821108341
Name:LEAVITT, MATT LOUIS (DO)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:LOUIS
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 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 1:260 LOOKOUT PL
Practice Address - Street 2:STE 103
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4485
Practice Address - Country:US
Practice Address - Phone:407-373-0700
Practice Address - Fax:407-333-2140
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS5365207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063702500Medicaid
FLE29656Medicare UPIN
FL80371ZMedicare PIN