Healthcare Provider Details

I. General information

NPI: 1134371669
Provider Name (Legal Business Name): LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8370 W FLAGLER ST SUITE 200
MIAMI FL
33144-2094
US

IV. Provider business mailing address

2600 LAKE LUCIEN DR SUITE 180
MAITLAND FL
32751-7233
US

V. Phone/Fax

Practice location:
  • Phone: 305-225-0400
  • Fax: 305-225-0450
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
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: NEFRITA LOGAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 407-875-2080