Healthcare Provider Details

I. General information

NPI: 1396978656
Provider Name (Legal Business Name): LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 COLLEGE PKWY
FORT MYERS FL
33907-5503
US

IV. Provider business mailing address

2600 LAKE LUCIEN DR
MAITLAND FL
32751-7233
US

V. Phone/Fax

Practice location:
  • Phone: 888-540-9660
  • Fax: 407-875-0518
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-875-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NEFRITA LOGAN
Title or Position: PROVIDER SERVICE REP
Credential:
Phone: 407-875-2080