1649560335 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Table of content: (NPI 1649560335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649560335 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVACNED DERMATOLOGY AND COSMETIC SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649560335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 LAKE LUCIEN DR
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-875-0518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 W REYNOLDS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-4743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-752-6824
Provider Business Practice Location Address Fax Number:
407-875-0518
Provider Enumeration Date:
04/14/2011

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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