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General NPI Number Information
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NPI Number | 1215319793
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Entity Type | Organization
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Legal Business Name | ORLANDO SKIN INSTITUTE, LLC
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Dates
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Enumeration Date | 06/22/2015
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Last Update Date | 06/22/2015
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Provider Practice Location Address
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Address Line | 110 POND CT STE 301
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City | DEBARY
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State | FL
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Zip | 32713
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Country | US
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Telephone | 386-742-0419
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Fax | 386-742-4119
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Provider Business Mailing Address
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Address Line | 110 POND CT STE 301
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City | DEBARY
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State | FL
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Zip | 32713
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Country | US
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Telephone | 386-742-0419
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Fax | 386-742-4119
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Authorized Official
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Title or Position | OWNER
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Name | GARY WATERMAN
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Credential | DO
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Telephone | 386-742-0419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | OS4781
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License Number State | FL
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