Healthcare Provider Details

I. General information

NPI: 1528097284
Provider Name (Legal Business Name): LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 INTERNATIONAL PKWY 240
HEATHROW FL
32746-5031
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7233
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-4200
  • Fax: 407-829-6637
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 NumberOS5365
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS5365
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberOS5365
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberOS5365
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberOS5365
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS5365
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberOS5365
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberOS5365
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS5365
License Number StateFL

VIII. Authorized Official

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