Healthcare Provider Details

I. General information

NPI: 1316105810
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: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8250 BRYAN DAIRY RD STE 250
LARGO FL
33777-1360
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 727-393-5300
  • Fax: 727-393-5301
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 State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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