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	:	1477708865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Provider Business Mailing Address
First Line	:	151 SOUTHHALL LN STE 300
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7172
Country	:	US
Telephone Number	:	407-875-2080
Fax Number	:	407-650-3455

Provider Business Practice Location Address
First Line	:	3006 17TH ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6011
Country	:	US
Telephone Number	:	407-498-7100
Fax Number	:	407-498-7200

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

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	07/21/2022

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