Provider Demographics
NPI:1730175886
Name:DISHAROON, PATRICIA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:MARIE
Last Name:DISHAROON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:MARLENE
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3414 ST. PAUL STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-889-3060
Mailing Address - Fax:410-243-8176
Practice Address - Street 1:3414 ST. PAUL STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-889-3060
Practice Address - Fax:410-243-8176
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22419207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD792201900Medicaid
MD2829Medicare ID - Type Unspecified
MD792201900Medicaid
B69249Medicare UPIN