Healthcare Provider Details

I. General information

NPI: 1194538777
Provider Name (Legal Business Name): BREANNA MITSUE ITO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

V. Phone/Fax

Practice location:
  • Phone: 760-560-7381
  • Fax:
Mailing address:
  • Phone: 760-560-7381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101290257
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: