Provider Demographics
NPI:1134259104
Name:GROSSMAN, KARYN L (MD)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:L
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 SANTA MONICA BLVD.
Mailing Address - Street 2:SUITE 1250W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2217
Mailing Address - Country:US
Mailing Address - Phone:310-998-0040
Mailing Address - Fax:310-998-0024
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 1250W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2217
Practice Address - Country:US
Practice Address - Phone:310-998-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG084212207N00000X, 207NS0135X
NY199318207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY199318OtherSTATE MEDICAL LICENSE
CAG84212OtherSTATE MEDICAL LICENSE
MA74551OtherSTATE MEDICAL LICENSE