Healthcare Provider Details

I. General information

NPI: 1811155377
Provider Name (Legal Business Name): LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 JOG RD SUITE 203
BOYNTON BEACH FL
33437-3535
US

IV. Provider business mailing address

2600 LAKE LUCIEN DR SUITE 180
MAITLAND FL
32751-7233
US

V. Phone/Fax

Practice location:
  • Phone: 561-244-6100
  • Fax: 561-244-6200
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-875-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NEFRITA LOGAN
Title or Position: PRO SER REP
Credential:
Phone: 407-875-2080