Provider Demographics
NPI:1538157011
Name:TYBERG, THEODORE I (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:I
Last Name:TYBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 61ST ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8795
Mailing Address - Country:US
Mailing Address - Phone:212-752-2000
Mailing Address - Fax:212-752-5822
Practice Address - Street 1:425 E 61ST ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8795
Practice Address - Country:US
Practice Address - Phone:212-752-2000
Practice Address - Fax:212-752-5822
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127630207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
6603052OtherGHI
NY9721OtherHEALTHNET
P3592993OtherOXFORD
6603052OtherGHI
NY21A971Medicare ID - Type Unspecified