Healthcare Provider Details

I. General information

NPI: 1265544357
Provider Name (Legal Business Name): EPIPHANY DERMATOLOGY OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 LANIER AVE W STE 270
FAYETTEVILLE GA
30214-7617
US

IV. Provider business mailing address

7300 RANCH ROAD 2222, BUILDING 1, STE 200
AUSTIN TX
78730
US

V. Phone/Fax

Practice location:
  • Phone: 770-251-5111
  • Fax:
Mailing address:
  • Phone: 512-628-0465
  • Fax: 512-233-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: GHEORGHE PUSTA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 512-628-0465