MEDICARE: LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1427216936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Provider Business Mailing Address
First Line	:	2600 LAKE LUCIEN DR STE 180
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7235
Country	:	US
Telephone Number	:	407-875-2080
Fax Number	:	407-875-0518

Provider Business Practice Location Address
First Line	:	49 ROYAL PALM PT STE 100
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-4270
Country	:	US
Telephone Number	:	772-569-5056
Fax Number	:	772-562-5098

Authorized Official
Title or Position	:	DIRECTOR, PROVIDER SERVICES
Name	:	AMY DECLUE
Credential	:
Telephone Number	:	407-875-2080

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	04/21/2010

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