Provider Demographics
NPI:1861606378
Name:PINE, ELYSE DARA (MD)
Entity type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:DARA
Last Name:PINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELYSE
Other - Middle Name:DARA
Other - Last Name:PINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1111 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5505
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:410-752-1374
Practice Address - Street 1:1111 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5505
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:410-752-1374
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD722662080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD554414900Medicaid