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
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	2086S0122X	Plastic and Reconstructive Surgery Physician
3	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1649560335
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
Second Line	:	SUITE 180
City	:	MAITLAND
State	:	FL
Zip	:	32751-7233
Country	:	US
Telephone Number	:	407-875-2080
Fax Number	:	407-875-0518

Provider Business Practice Location Address
First Line	:	2005 W REYNOLDS ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-4743
Country	:	US
Telephone Number	:	813-752-6824
Fax Number	:	407-875-0518

Authorized Official
Title or Position	:	PROVIDER SERVICE REP
Name	:	NEFRITA LOGAN
Credential	:
Telephone Number	:	407-875-2080

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	11/16/2011

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