MEDICARE: JUNIPER DERMATOLOGY PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	207ND0900X	Dermatopathology Physician
3	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1578135539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUNIPER DERMATOLOGY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1030
Second Line	:
City	:	SANTA YNEZ
State	:	CA
Zip	:	93460-1030
Country	:	US
Telephone Number	:	512-808-4777
Fax Number	:	512-808-4779

Provider Business Practice Location Address
First Line	:	3801 N CAPITAL OF TEXAS HWY STE J225
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78746-1499
Country	:	US
Telephone Number	:	805-453-6060
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. BRYAN GAMMON
Credential	:	MD
Telephone Number	:	512-808-4777

Provider Enumeration Date	:	07/10/2021
Last Update Date	:	08/14/2023

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