Basic Information
Provider Information | |||||||||
NPI: | 1316105885 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED DERMATOLOGY AND COSMETIC SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 151 SOUTHHALL LN | ||||||||
Address2: | STE 300 | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 327517176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078752080 | ||||||||
FaxNumber: | 4076503455 | ||||||||
Practice Location | |||||||||
Address1: | 2116 S ORANGE AVE | ||||||||
Address2: | STE C | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328063037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4077700139 | ||||||||
FaxNumber: | 4077700182 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2008 | ||||||||
LastUpdateDate: | 05/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DECLUE | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER SERVICES | ||||||||
AuthorizedOfficialTelephone: | 4078752080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208200000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 207N00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 256877223 | 05 | FL |   | MEDICAID |