# PURE SKINOLOGY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1649807074
- **Authorized official:** DR. DAVID OTHMAN MD (PRESIDENT)
- **Authorized official phone:** (312) 600-5826

## Contact information

- **Practice address:** 2202 N. HALSTED ST, SUITE 1, CHICAGO, IL 60614
- **Practice address phone:** (773) 270-1133
- **Mailing address:** 2202 N. HALSTED ST, SUITE 1, CHICAGO, IL 60614
- **Mailing address phone:** (312) 600-5826
- **Mailing address fax:** (608) 713-8272

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207N00000X | Dermatology Physician | — | NULL | — |
| 207N00000X | Dermatology Physician | — | — | — |
| 207ND0101X | MOHS-Micrographic Surgery Physician | — | NULL | — |
| 207ND0101X | MOHS-Micrographic Surgery Physician | — | — | — |
| 207ND0900X | Dermatopathology Physician | — | NULL | — |
| 207ND0900X | Dermatopathology Physician | — | — | — |
| 207NI0002X | Clinical & Laboratory Dermatological Immunology Physician | — | NULL | — |
| 207NI0002X | Clinical & Laboratory Dermatological Immunology Physician | — | — | — |
| 207NP0225X | Pediatric Dermatology Physician | — | NULL | — |
| 207NP0225X | Pediatric Dermatology Physician | — | — | — |
| 207NS0135X | Procedural Dermatology Physician | — | NULL | — |
| 207NS0135X | Procedural Dermatology Physician | — | — | — |
| 261QA1903X | Ambulatory Surgical Clinic/Center | — | NULL | — |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 03/25/2020
- **Last updated:** 07/15/2020