Provider Demographics
NPI:1194100081
Name:TUBRE, TEDDI LYNN (MD)
Entity type:Individual
Prefix:
First Name:TEDDI
Middle Name:LYNN
Last Name:TUBRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TEDDI
Other - Middle Name:LYNN
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-5057
Mailing Address - Fax:401-606-1233
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5057
Practice Address - Fax:401-606-1233
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP05000207ZN0500X
NETEP7574207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology