Leavitt Medical Associates of Florida Inc
Organization Active NPI Dermatology Physician · Port Orange, FL
NPI 1093973588 · NPPES record last updated Apr 21, 2010
Key facts
- NPI
- 1093973588
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- Legal business name
- LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
- Practice address
- 1720 Dunlawton Ave Ste 2
Port Orange, FL 32127-2916 - Phone
- (386) 322-8310
- Fax
- (386) 322-8370
- NPI assigned
- May 30, 2008
- Organization subpart
- Yes
- Parent organization (as reported)
- LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Authorized official
- Name
- Amy Declue
- Title
- Director, Provider Services
- Phone
- (407) 875-2080
Corporate family (same tax ID) 22
Practitioners 9
-
Daysi Mariel Abreu, PHYSICIAN ASSISTANT
-
Christina Michelle Baden, PA-C
-
Christopher Bergin, PA-C
-
Cristian Gallo, PA-C
-
Josep Genebriera de Lamo, M.D.
-
Jason D. Kieffer, MD
-
Stephen McAskill, MD
-
Christine E Moorhead, M.D.
-
Sonya Unnoppet, PA
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2158831 | Advanced Dermatology and Cosmetic Surgery | Accreditation | Jun 8, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050228000737 | FL | Part B Supplier - Clinic/Group Practice | 4688579311 |
Receives reassigned benefits from 243 practitioners This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Leavitt Medical Associates of Florida Inc
- Part of
- Leavitt Medical Associates of Florida Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician |
207N00000X | Yes | ||
| MOHS-Micrographic Surgery Physician |
207ND0101X | |||
| Family Medicine Physician |
207Q00000X | |||
| Plastic Surgery Physician |
208200000X |
Addresses
Primary practice location
1720 Dunlawton Ave Ste 2
Port Orange, FL 32127-2916
Mailing address
2600 Lake Lucien Dr Ste 180
Maitland, FL 32751-7235
Phone (407) 875-2080
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 256877216 | Medicaid | FL |
Other names
- Advanced Dermatology and Cosmetic Surgery
Other providers in Port Orange, FL
- Karen A Laudisio
- Imelda C Lavarias
- Brandon Lavelle
- Madiey F. Lawindy
- Latrellini Lawrence
- Sarah Leblanc
- Marcie Rachele Lebrun
- Ashley Leclerc-Pellerin
- E. Joseph Lecompte
- Cheng-Han Lee
All providers in Port Orange, FL · Dermatology Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 21, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.