Healthcare Provider Details

I. General information

NPI: 1043754526
Provider Name (Legal Business Name): MD TRUCARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 IRA E WOODS AVE STE 200
GRAPEVINE TX
76051-4096
US

IV. Provider business mailing address

PO BOX 93685
SOUTHLAKE TX
76092-0116
US

V. Phone/Fax

Practice location:
  • Phone: 817-722-6078
  • Fax: 817-722-6077
Mailing address:
  • Phone: 218-205-0198
  • Fax: 817-722-6077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AYESHA EBRAHIM
Title or Position: CEO
Credential:
Phone: 218-205-0198