Provider Demographics
NPI:1194967331
Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Entity type:Organization
Organization Name:LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:NEFRITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:2600 LAKE LUCIEN DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7233
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:410 CELEBRATION PL
Practice Address - Street 2:SUITE 301
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5433
Practice Address - Country:US
Practice Address - Phone:407-566-1616
Practice Address - Fax:407-566-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98046Medicare UPIN