Healthcare Provider Details

I. General information

NPI: 1891953303
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: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 DEL PRADO BLVD N SUITE 201
CAPE CORAL FL
33909-2278
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 239-829-7102
  • Fax: 239-829-7102
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY DECLUE
Title or Position: DIRECTOR, PROVIDER SERVICES
Credential:
Phone: 407-875-2080