Provider Demographics
NPI:1124331350
Name:LEAVITT DERMATOPATHOLOGY, LLC
Entity type:Organization
Organization Name:LEAVITT DERMATOPATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PROVIDER SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:1300 NW 17TH AVE STE 130
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2588
Practice Address - Country:US
Practice Address - Phone:561-819-0857
Practice Address - Fax:561-549-0173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty