Provider Demographics
NPI:1457465858
Name:EPIPHANY DERMATOLOGY OF ARIZONA, LLC
Entity Type:Organization
Organization Name:EPIPHANY DERMATOLOGY OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GHEORGHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-628-0465
Mailing Address - Street 1:7300 RANCH RD. 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-628-0468
Practice Address - Street 1:7767 W DEER VALLEY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2103
Practice Address - Country:US
Practice Address - Phone:623-487-3003
Practice Address - Fax:623-487-0952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ63140OtherMEDICARE GROUP PTAN