1730175886 NPI number — DR. PATRICIA MARIE DISHAROON MD

Table of content: DR. PATRICIA MARIE DISHAROON MD (NPI 1730175886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730175886 NPI number — DR. PATRICIA MARIE DISHAROON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DISHAROON
Provider First Name:
PATRICIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UNDERWOOD
Provider Other First Name:
ELLEN
Provider Other Middle Name:
MARLENE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1730175886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3414 ST. PAUL STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-889-3060
Provider Business Mailing Address Fax Number:
410-243-8176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3414 ST. PAUL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-889-3060
Provider Business Practice Location Address Fax Number:
410-243-8176
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D22419 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 792201900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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