MEDICARE: EPIPHANY DERMATOLOGY OF MARYLAND PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1215721501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPIPHANY DERMATOLOGY OF MARYLAND PA

Provider Business Mailing Address
First Line	:	7300 RANCH ROAD 2222, BLDG 1, STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730
Country	:	US
Telephone Number	:	512-628-0465
Fax Number	:

Provider Business Practice Location Address
First Line	:	6535 N CHARLES ST STE 200
Second Line	:
City	:	TOWSON
State	:	MD
Zip	:	21204-5823
Country	:	US
Telephone Number	:	410-321-1195
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	GHEORGHE PUSTA
Credential	:
Telephone Number	:	512-628-0465

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	11/12/2025

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