Basic Information
| Provider Information | |||||||||
| NPI: | 1528226081 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC | ||||||||
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| OtherOrganizationName: | ADVANCED DERMATOLOGY AND COSMETIC SUR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 LAKE LUCIEN DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4078750518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 NW 17TH AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334452578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618190957 | ||||||||
| FaxNumber: | 5615490173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | NEFRITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROV SER REP | ||||||||
| AuthorizedOfficialTelephone: | 4078752080 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 256877213 | 05 | FL | MEDICAID |