Provider Demographics
NPI:1972833754
Name:EBRAHIM, ELLAHEH (MD)
Entity Type:Individual
Prefix:
First Name:ELLAHEH
Middle Name:
Last Name:EBRAHIM
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 1:200 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-1152
Mailing Address - Country:US
Mailing Address - Phone:940-766-6306
Mailing Address - Fax:940-766-6504
Practice Address - Street 1:200 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-1152
Practice Address - Country:US
Practice Address - Phone:940-766-6306
Practice Address - Fax:940-766-6504
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27109207Q00000X, 281P00000X, 282N00000X
TXN8909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No281P00000XHospitalsChronic Disease Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK39976OtherOSBNDD