Provider Demographics
NPI:1043754526
Name:MD TRUCARE PA
Entity Type:Organization
Organization Name:MD TRUCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AYESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-205-0198
Mailing Address - Street 1:PO BOX 93685
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0116
Mailing Address - Country:US
Mailing Address - Phone:218-205-0198
Mailing Address - Fax:817-722-6077
Practice Address - Street 1:823 IRA E WOODS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4096
Practice Address - Country:US
Practice Address - Phone:817-722-6078
Practice Address - Fax:817-722-6077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty