Basic Information
| Provider Information | |||||||||
| NPI: | 1891953303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC | ||||||||
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| OtherOrganizationName: | ADVANCED DERMATOLOGY AND COSMETIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 632 DEL PRADO BLVD N | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339092278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2398297102 | ||||||||
| FaxNumber: | 2398297102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | DECLUE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER SERVICES | ||||||||
| 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 | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.