Healthcare Provider Details

I. General information

NPI: 1598025447
Provider Name (Legal Business Name): PURE SKIN DERMATOLOGY AND AESTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7932 W SAND LAKE RD SUITE 206
ORLANDO FL
32819-7263
US

IV. Provider business mailing address

7932 W SAND LAKE RD SUITE 206
ORLANDO FL
32819-7263
US

V. Phone/Fax

Practice location:
  • Phone: 407-900-2580
  • Fax:
Mailing address:
  • Phone: 407-900-2580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME98190
License Number StateFL

VIII. Authorized Official

Name: DR. DEBRA L GRAYMAN
Title or Position: MGRM
Credential: M.D.
Phone: 407-900-2580