Provider Demographics
NPI:1881925006
Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity type:Organization
Organization Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER SERVICE 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 1:151 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 1:1515 W NASA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2605
Practice Address - Country:US
Practice Address - Phone:321-308-0659
Practice Address - Fax:321-309-2881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-28
Last Update Date:2013-12-09
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
FL98046HMedicare PIN