Provider Demographics
NPI:1831167188
Name:JILA S WAIKHOM M D &ASSOCIATES INC
Entity type:Organization
Organization Name:JILA S WAIKHOM M D &ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAIKHOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-426-8235
Mailing Address - Street 1:440 SUGARBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-9760
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0471903Medicaid
OHJI9914922Medicare PIN
OHD31956Medicare UPIN