NPIMap

Organization Active NPI

Leavitt Medical Associates of Florida Inc

Doing business as Advanced Dermatology and Cosmetic Surgery

  • Dermatology Physician
  • Palm Coast, FL
National Provider Identifier
1902067671
Registry record updated Apr 21, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
Doing business as
Advanced Dermatology and Cosmetic Surgery
Practice address
3 Pine Cone Dr
Suite 102
Palm Coast, FL 32137-8685
Phone
(888) 540-9660
Fax
(407) 875-0518
NPI assigned
Jun 24, 2008
Last updated
Apr 21, 2010By the provider in NPPES
Organization subpart
Yes
Parent organization
LEAVITT MEDICAL ASSOCIATES OF FLORIDA INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 21, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amy Declue
Title
Director, Provider Services
Phone
(407) 875-2080

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X NU Primary
MOHS-Micrographic Surgery Physician 207ND0101X NU
Plastic Surgery Physician 208200000X NU

Addresses

Primary practice location

3 Pine Cone Dr
Suite 102
Palm Coast, FL 32137-8685

Mailing address

2600 Lake Lucien Dr Ste 180
Maitland, FL 32751-7235
Phone (407) 875-2080

Other names 1

  • Advanced Dermatology and Cosmetic Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050228000737 FL Part B Supplier - Clinic/Group Practice 4688579311 Receives reassigned benefits from 243 practitioners
This NPI is an additional NPI on the enrollment

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2157867Advanced Dermatology and Cosmetic Surgery3 Pine Cone Dr Ste 102, Palm Coast, FL 32137Provider-performed microscopyApr 30, 2027

National Provider Directory

National Provider Directory
Tax ID family
Leavitt Med Aso of FL Inc23 organizations share this tax ID, including this one
Part of
Leavitt Med Aso of FL Inc

Other organizations with this tax ID 22

Organizations that report the same tax identification number in the National Provider Directory.

View all 22

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1214265600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1271808000000",
    "number": "1902067671",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2600 LAKE LUCIEN DR STE 180",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327517235",
            "telephone_number": "407-875-2080",
            "fax_number": "407-875-0518"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3 PINE CONE DR",
            "address_2": "SUITE 102",
            "city": "PALM COAST",
            "state": "FL",
            "postal_code": "321378685",
            "telephone_number": "888-540-9660",
            "fax_number": "407-875-0518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC",
        "enumeration_date": "2008-06-24",
        "last_updated": "2010-04-21",
        "status": "A",
        "authorized_official_last_name": "DECLUE",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "DIRECTOR, PROVIDER SERVICES",
        "authorized_official_telephone_number": "407-875-2080"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Dermatology and Cosmetic Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Palm Coast, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 21, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.