1538235569 NPI number — DR. ANDREW CLARK LEAVITT MD

Table of content: DR. ANDREW CLARK LEAVITT MD (NPI 1538235569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538235569 NPI number — DR. ANDREW CLARK LEAVITT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT
Provider First Name:
ANDREW
Provider Middle Name:
CLARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1538235569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34995-0417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-223-2832
Provider Business Mailing Address Fax Number:
772-223-5996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 S KANNER HWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-288-5881
Provider Business Practice Location Address Fax Number:
772-223-5996
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  ME0056754 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X , with the licence number: ME0056754 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME0056754 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015084000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10401 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 110962800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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