Provider Demographics
NPI:1992297469
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:512-628-0465
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 1:3773 CHERRY CREEK N. DR #970
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3804
Practice Address - Country:US
Practice Address - Phone:303-388-5629
Practice Address - Fax:303-321-7586
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EPIPHANY BUSINESS SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-31
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty