MEDICARE: ALEXANDER P. VILAYTHONG DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	N7760	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447410535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER P. VILAYTHONG DO

Provider Business Mailing Address
First Line	:	1650 W MAGNOLIA AVE
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4009
Country	:	US
Telephone Number	:	817-912-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 W MAGNOLIA AVE
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4009
Country	:	US
Telephone Number	:	817-926-2544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	02/14/2012

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