NPIMap

Organization Active NPI

MD Trucare PA

  • Endocrinology, Diabetes & Metabolism Physician
  • Grapevine, TX
National Provider Identifier
1043754526
Registry record updated Mar 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Endocrinology, Diabetes & Metabolism PhysicianTaxonomy code 207RE0101X
Legal business name
MD TRUCARE PA
Practice address
823 Ira E Woods Ave Ste 200
Grapevine, TX 76051-4096
Phone
(817) 722-6078
Fax
(817) 722-6077
NPI assigned
Dec 19, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ayesha EbrahimNPI 1831144609
Title
Ceo
Phone
(218) 205-0198

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Endocrinology, Diabetes & Metabolism PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RE0101X Primary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X

Addresses

Primary practice location

823 Ira E Woods Ave Ste 200
Grapevine, TX 76051-4096

Mailing address

PO Box 93685
Southlake, TX 76092-0116
Phone (218) 205-0198

Other practice location 1

10640 N Riverside Dr Ste 300
Fort Worth, TX 76244-9507
Phone (817) 722-6078

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170127002129 TX Part B Supplier - Clinic/Group Practice 1557643467 Receives reassigned benefits from 34 practitioners
Practice locations: Fort Worth, TX; Grapevine, TX

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D2165884MD Trucare, PA823 Ira E Woods Suite 200, Grapevine, TX 76051Certificate of waiverMay 6, 2027
45D2266492MD Trucare10640 N Riverside Dr Suite 300, Fort Worth, TX 76244Certificate of waiverAug 10, 2026

National Provider Directory

National Provider Directory

Locations

10640 N Riverside Dr
Ste 300
Fort Worth, TX 76244
Phone (817) 722-6078

300 State St
Unit 93685
Grapevine, TX 76092

121 W Lamberth Rd
Ste A
Sherman, TX 75092
Phone (218) 205-8475

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/AJHDBD

Practitioners & affiliated clinicians

Practitioners 34

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 34

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1482105600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646352000000",
    "number": "1043754526",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 93685",
            "city": "SOUTHLAKE",
            "state": "TX",
            "postal_code": "760920116",
            "telephone_number": "218-205-0198",
            "fax_number": "817-722-6077"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "823 IRA E WOODS AVE STE 200",
            "city": "GRAPEVINE",
            "state": "TX",
            "postal_code": "760514096",
            "telephone_number": "817-722-6078",
            "fax_number": "817-722-6077"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10640 N Riverside Dr Ste 300",
            "address_purpose": "LOCATION",
            "city": "Fort Worth",
            "state": "TX",
            "postal_code": "762449507",
            "country_code": "US",
            "telephone_number": "817-722-6078",
            "fax_number": "817-722-6077",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MD TRUCARE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-19",
        "last_updated": "2022-03-04",
        "certification_date": "2022-03-04",
        "status": "A",
        "authorized_official_last_name": "EBRAHIM",
        "authorized_official_first_name": "AYESHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "218-205-0198",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "207RE0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grapevine, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.