Provider Demographics
NPI:1447410535
Name:VILAYTHONG, ALEXANDER P (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:P
Last Name:VILAYTHONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W MAGNOLIA AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4009
Mailing Address - Country:US
Mailing Address - Phone:817-912-8000
Mailing Address - Fax:
Practice Address - Street 1:1650 W MAGNOLIA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4009
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN7760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286104901Medicaid
TX286104902Medicaid
TXTXB137762Medicare PIN
TXTXB141820Medicare PIN