Healthcare Provider Details

I. General information

NPI: 1215721501
Provider Name (Legal Business Name): EPIPHANY DERMATOLOGY OF MARYLAND PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 N CHARLES ST STE 200
TOWSON MD
21204-5823
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 410-321-1195
  • Fax:
Mailing address:
  • Phone: 512-628-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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