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General NPI Number Information
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NPI Number | 1881429504
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Entity Type | Organization
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Legal Business Name | ADVANCED DERMATOLOGY OF MARYLAND PC
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Dates
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Enumeration Date | 09/03/2024
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 174 WATERFRONT STREET SUITE 200
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City | NATIONAL HARBOR
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State | MD
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Zip | 20745-1164
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Country | US
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Telephone | 240-766-8116
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Fax |
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Provider Business Mailing Address
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Address Line | 151 SOUTHHALL LN STE 300
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City | MAITLAND
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State | FL
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Zip | 32751-7172
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Country | US
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Telephone | 407-875-2080
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATT LOUIS LEAVITT
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Credential | DO
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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 | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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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 |
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