Healthcare Provider Details

I. General information

NPI: 1124331350
Provider Name (Legal Business Name): LEAVITT DERMATOPATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 NW 17TH AVE STE 130
DELRAY BEACH FL
33445-2588
US

IV. Provider business mailing address

151 SOUTHHALL LN SUITE 300
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 561-819-0857
  • Fax: 561-549-0173
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-875-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

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