Provider Demographics
NPI:1629034103
Name:VIDYASAGARAN, JILLY KUNJUNNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JILLY
Middle Name:KUNJUNNY
Last Name:VIDYASAGARAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1902
Mailing Address - Country:US
Mailing Address - Phone:713-944-2324
Mailing Address - Fax:713-944-1539
Practice Address - Street 1:4024 BROOKHAVEN AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1902
Practice Address - Country:US
Practice Address - Phone:713-944-2324
Practice Address - Fax:713-944-1539
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2829208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1270928-05OtherTHSTEPS
TX1270928-03Medicaid
TX1270928-03Medicaid