1992095681 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992095681 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:
1992095681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2011
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:
3427 MARINER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING HILL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34609-2463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-540-9660
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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