Provider Demographics
NPI:1104189745
Name:DISHAROON, MEREDITH LYNN (DO)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:LYNN
Last Name:DISHAROON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:LYNN
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:PO BOX 30750
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0750
Mailing Address - Country:US
Mailing Address - Phone:252-931-7638
Mailing Address - Fax:
Practice Address - Street 1:1400 DOWELL SPRINGS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2457
Practice Address - Country:US
Practice Address - Phone:865-584-0291
Practice Address - Fax:865-584-4426
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010201152085R0202X
NC2018-008482085R0202X
TN033172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104189745Medicaid
TNQ060923Medicaid