Healthcare Provider Details

I. General information

NPI: 1417070426
Provider Name (Legal Business Name): JILA S WAIKHOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SUGARBROOK TRL
BELLBROOK OH
45305-9760
US

IV. Provider business mailing address

PO BOX 252
BELLBROOK OH
45305-0252
US

V. Phone/Fax

Practice location:
  • Phone: 937-426-8235
  • Fax:
Mailing address:
  • Phone: 937-426-8235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number36762
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: