Provider Demographics
NPI:1043054497
Name:DERMA GLOW MED SPA CORP
Entity type:Organization
Organization Name:DERMA GLOW MED SPA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:KAZEMI
Authorized Official - Last Name:SHOJAYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-641-1406
Mailing Address - Street 1:22237 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3315
Mailing Address - Country:US
Mailing Address - Phone:440-641-1406
Mailing Address - Fax:
Practice Address - Street 1:22237 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3315
Practice Address - Country:US
Practice Address - Phone:440-641-1406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-20
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty