Provider Demographics
NPI:1306669395
Name:BENSOUDA, IBRAHIM (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MR
First Name:IBRAHIM
Middle Name:
Last Name:BENSOUDA
Suffix:
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9088 TANYARD LN
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 TYSONS BLVD FL 5
Practice Address - Street 2:
Practice Address - City:TYSONS
Practice Address - State:VA
Practice Address - Zip Code:22102-4285
Practice Address - Country:US
Practice Address - Phone:703-459-8656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86358477133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered