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General NPI Number Information
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NPI Number | 1801191101
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Entity Type | Organization
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Legal Business Name | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
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Dates
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Enumeration Date | 01/18/2011
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 2902 59TH ST W SUITE A
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City | BRADENTON
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State | FL
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Zip | 34209-7023
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Country | US
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Telephone | 941-757-0763
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Fax | 941-757-0725
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Provider Business Mailing Address
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Address Line | 151 SOUTHHALL LN SUITE 300
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City | MAITLAND
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State | FL
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Zip | 32751-7176
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Country | US
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Telephone | 407-875-2080
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Fax | 407-650-3455
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Authorized Official
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Title or Position | DIRECTOR, PROVIDER SERVICES
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Name | AMY DECLUE
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Credential |
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Telephone | 407-875-2080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State | FL
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