Provider Demographics
NPI:1356338206
Name:IBIA, ITORO (MD)
Entity type:Individual
Prefix:DR
First Name:ITORO
Middle Name:
Last Name:IBIA
Suffix:
Gender:F
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:PO BOX 2963
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0963
Mailing Address - Country:US
Mailing Address - Phone:703-707-9777
Mailing Address - Fax:703-707-0690
Practice Address - Street 1:11701 BOWMAN GREEN DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3573
Practice Address - Country:US
Practice Address - Phone:703-707-9777
Practice Address - Fax:703-707-0690
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012230342084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F480-0001OtherCARE FIRST BCBS ID
2037353OtherCIGNA ID
VA466688OtherANTHEM BCBS ID
7267195OtherAETNA PROVIDER ID
2037353OtherCIGNA ID