Healthcare Provider Details

I. General information

NPI: 1861606378
Provider Name (Legal Business Name): ELYSE DARA PINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELYSE DARA PINE M.D.

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

IV. Provider business mailing address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2050
  • Fax: 410-752-1374
Mailing address:
  • Phone: 410-837-2050
  • Fax: 410-752-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberD72266
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD72266
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: