Provider Demographics
NPI:1538773775
Name:ADVANCED DERMATOLOGY OF ALABAMA, INC.
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF ALABAMA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:286 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:407-875-2080
Practice Address - Fax:407-650-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty