Provider Demographics
NPI:1164476503
Name:STUBBE, INGO H (MD)
Entity Type:Individual
Prefix:
First Name:INGO
Middle Name:H
Last Name:STUBBE
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 1:45 HUNNEWELL ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5411
Mailing Address - Country:US
Mailing Address - Phone:781-237-5077
Mailing Address - Fax:
Practice Address - Street 1:230 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1408
Practice Address - Country:US
Practice Address - Phone:617-591-4920
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3134105Medicaid
MA3134105Medicaid
MAF94892Medicare UPIN