Healthcare Provider Details

I. General information

NPI: 1477708865
Provider Name (Legal Business Name): LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3006 17TH ST
SAINT CLOUD FL
34769-6011
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 407-498-7100
  • Fax: 407-498-7200
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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