Healthcare Provider Details

I. General information

NPI: 1104084672
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: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14050 TOWN LOOP BLVD STE 203
ORLANDO FL
32837-6190
US

IV. Provider business mailing address

2600 LAKE LUCIEN DR STE 180
MAITLAND FL
32751-7235
US

V. Phone/Fax

Practice location:
  • Phone: 407-852-6650
  • Fax: 407-852-6035
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-875-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

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