Provider Demographics
NPI:1720519226
Name:LEAVITT, ADAM ROSS (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:ROSS
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:120 INTERNATIONAL PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:HEATHROW
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5033
Mailing Address - Country:US
Mailing Address - Phone:407-675-6733
Mailing Address - Fax:
Practice Address - Street 1:2915 LAKEVIEW DR STE 32730
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2050
Practice Address - Country:US
Practice Address - Phone:407-834-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-26
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150502207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery