Provider Demographics
NPI:1861925901
Name:IBEANU, IJEOMA CAROL (MD)
Entity type:Individual
Prefix:
First Name:IJEOMA
Middle Name:CAROL
Last Name:IBEANU
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 1:5340 EL PASO DR STE M
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2838
Mailing Address - Country:US
Mailing Address - Phone:915-242-8402
Mailing Address - Fax:915-242-8404
Practice Address - Street 1:5340 EL PASO DR STE M
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2838
Practice Address - Country:US
Practice Address - Phone:915-242-8402
Practice Address - Fax:915-242-8404
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-03332084P0804X, 2084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program