Provider Demographics
NPI:1851516868
Name:WAIKHOM, SURAJ (MD)
Entity Type:Individual
Prefix:
First Name:SURAJ
Middle Name:
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 1:3405 STONEVISTA LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-4942
Mailing Address - Country:US
Mailing Address - Phone:513-257-8725
Mailing Address - Fax:
Practice Address - Street 1:3405 STONEVISTA LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-4942
Practice Address - Country:US
Practice Address - Phone:513-257-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0872252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology