=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174697239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPIPHANY DERMATOLOGY OF OREGON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 NW LOVEJOY ST SUITE 422
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97210-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-227-7117
-----------------------------------------------------
Fax | 503-227-7120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 RANCH ROAD 2222, BLDG 1, STE 200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78730-3255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-628-0465
-----------------------------------------------------
Fax | 512-233-2711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | GHEORGHE PUSTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-628-0465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------