Basic Information
| Provider Information | |||||||||
| NPI: | 1942430285 | ||||||||
| 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: | 2600 LAKE LUCIEN DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4078750518 | ||||||||
| Practice Location | |||||||||
| Address1: | 14810 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044006565 | ||||||||
| FaxNumber: | 9044006560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | NEFRITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER SERVICE 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 | 207ND0101X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 363A00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207N00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.