Provider Demographics
NPI:1912107038
Name:VILAYTHONG, JILL NGEUN (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:NGEUN
Last Name:VILAYTHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NGEUN
Other - Middle Name:
Other - Last Name:VILAYTHONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:19222 STONEHUE STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3454
Mailing Address - Country:US
Mailing Address - Phone:210-890-1952
Mailing Address - Fax:210-396-7736
Practice Address - Street 1:19222 STONEHUE STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3454
Practice Address - Country:US
Practice Address - Phone:210-890-1952
Practice Address - Fax:210-396-7736
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31298207R00000X, 207R00000X
TXN6754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200590800 AMedicaid
OKP01599610OtherRR MEDICARE
OKP01599610OtherRR MEDICARE