Provider Demographics
NPI:1598025447
Name:PURE SKIN DERMATOLOGY AND AESTHETICS, LLC
Entity Type:Organization
Organization Name:PURE SKIN DERMATOLOGY AND AESTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-900-2580
Mailing Address - Street 1:7932 W SAND LAKE RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7263
Mailing Address - Country:US
Mailing Address - Phone:407-900-2580
Mailing Address - Fax:
Practice Address - Street 1:7932 W SAND LAKE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7263
Practice Address - Country:US
Practice Address - Phone:407-900-2580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98190207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1598025447OtherGROUP NPI