Organization
EPIPHANY DERMATOLOGY PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GHEORGHE PUSTA (CEO)
(512) 628-0465
Entity
Organization
Contact information
Practice address
7106 SANGER AVENUE, WACO, TX 76712-3928
(254) 537-1265
(254) 537-1310
Mailing address
7300 RANCH ROAD 2222, BLDG 1, STE 200, AUSTIN, TX 78730-3255
(512) 628-0465
(512) 628-0468
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
Q1815
TX
207ND0101X
MOHS-Micrographic Surgery Physician
Q1815
TX
261QR0200X
Radiology Clinic/Center
—
—
Other
Enumeration date
10/30/2014
Last updated
07/21/2023
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