Basic Information
Provider Information | |||||||||
NPI: | 1942543541 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DISPENZA | ||||||||
FirstName: | MELANIE | ||||||||
MiddleName: | CLAIRE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9910 FRANKLIN SQUARE DR STE 2110 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212364902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109336423 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5501 HOPKINS BAYVIEW CIR | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 21224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105502300 | ||||||||
FaxNumber: | 4105503256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2013 | ||||||||
LastUpdateDate: | 08/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036140029 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0201X | 036140029 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 390200000X |   | IL | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RA0201X | D87781 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology |
ID Information
ID | Type | State | Issuer | Description | 036140029 | 01 | IL | MEDICAL LICENSE | OTHER |