=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912107038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL NGEUN VILAYTHONG M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 06/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19222 STONEHUE STE 103
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-890-1952
-----------------------------------------------------
Fax | 210-396-7736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19222 STONEHUE STE 103
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-890-1952
-----------------------------------------------------
Fax | 210-396-7736
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 31298
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | N6754
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------