Healthcare Provider Details

I. General information

NPI: 1447615760
Provider Name (Legal Business Name): EPIPHANY DERMATOLOGY OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 EUBANK BLVD NE STE 110
ALBUQUERQUE NM
87111-1519
US

IV. Provider business mailing address

7300 RANCH RD. 2222, BLDG 1, STE 200
AUSTIN TX
78730-3255
US

V. Phone/Fax

Practice location:
  • Phone: 512-628-0465
  • Fax: 512-628-0468
Mailing address:
  • Phone: 512-628-0465
  • Fax: 512-628-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number88-97
License Number StateNM

VIII. Authorized Official

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