1679712269 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Table of content: (NPI 1679712269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679712269 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:
ADVANCED 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:
1679712269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2010
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:
8501 SW 124TH AVE
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33183-4627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-273-6001
Provider Business Practice Location Address Fax Number:
305-273-6097
Provider Enumeration Date:
02/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LOGAN
Authorized Official First Name:
NEFRITA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COR
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" .

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





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