Provider Demographics
NPI:1538235569
Name:LEAVITT, ANDREW CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CLARK
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5996
Practice Address - Street 1:3801 S KANNER HWY STE 300
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4801
Practice Address - Country:US
Practice Address - Phone:772-288-5881
Practice Address - Fax:772-223-5996
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056754207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015084000Medicaid
FL10401OtherFLORIDA BLUE