Healthcare Provider Details

I. General information

NPI: 1356338206
Provider Name (Legal Business Name): ITORO IBIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 BOWMAN GREEN DR
RESTON VA
20190-3573
US

IV. Provider business mailing address

PO BOX 2963
RESTON VA
20195-0963
US

V. Phone/Fax

Practice location:
  • Phone: 703-707-9777
  • Fax: 703-707-0690
Mailing address:
  • Phone: 703-707-9777
  • Fax: 703-707-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101223034
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101223034
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: