Provider Demographics
NPI:1194340802
Name:EPIPHANY DERMATOLOGY OF COLORADO, LLC
Entity type:Organization
Organization Name:EPIPHANY DERMATOLOGY OF COLORADO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GHEORGHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-960-5760
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:
Practice Address - Street 1:2530 N 8TH ST STE 205
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8858
Practice Address - Country:US
Practice Address - Phone:970-245-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-09
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty