Provider Demographics
NPI:1053576140
Name:WAIKHOM, BANDANA (MD)
Entity type:Individual
Prefix:
First Name:BANDANA
Middle Name:
Last Name:WAIKHOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1686
Mailing Address - Country:US
Mailing Address - Phone:859-746-1990
Mailing Address - Fax:859-746-3149
Practice Address - Street 1:7370 TURFWAY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4895
Practice Address - Country:US
Practice Address - Phone:859-746-1990
Practice Address - Fax:859-746-3149
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.084676207W00000X
KYTP202207W00000X
KY48047207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2925937Medicaid
KY7100136710Medicaid
KY7100136710Medicaid