=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255626297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2011
-----------------------------------------------------
Last Update Date | 08/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 N OLIVE AVE
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33401-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-835-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 LAKE LUCIEN DR SUITE 180
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-875-2080
-----------------------------------------------------
Fax | 407-875-0518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER SERIVCE REP
-----------------------------------------------------
Name | NEFRITA LOGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-875-2080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------