Provider Demographics
NPI:1417070426
Name:WAIKHOM, JILA S (MD)
Entity Type:Individual
Prefix:
First Name:JILA
Middle Name:S
Last Name:WAIKHOM
Suffix:
Gender:M
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:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-0252
Mailing Address - Country:US
Mailing Address - Phone:937-426-8235
Mailing Address - Fax:
Practice Address - Street 1:440 SUGARBROOK TRL
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-9760
Practice Address - Country:US
Practice Address - Phone:937-426-8235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0245256Medicaid
OH0245256Medicaid
OHWA0400154Medicare PIN