Healthcare Provider Details

I. General information

NPI: 1770699662
Provider Name (Legal Business Name): ANA R IBANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13605 BADEN WESTWOOD ROAD
BRANDYWINE MD
20613
US

IV. Provider business mailing address

9440 PENNSYLVANIA AVENUE 160
UPPER MARLBORO MD
20772-3687
US

V. Phone/Fax

Practice location:
  • Phone: 301-888-2233
  • Fax:
Mailing address:
  • Phone: 301-599-0460
  • Fax: 301-599-0463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0032959
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: