Healthcare Provider Details

I. General information

NPI: 1801014394
Provider Name (Legal Business Name): M B KAYANI PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W BARNEY ST
GOUVERNEUR NY
13642-1040
US

IV. Provider business mailing address

1815 STATE ST
WATERTOWN NY
13601-9406
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-3638
  • Fax: 315-287-3656
Mailing address:
  • Phone: 315-788-6070
  • Fax: 315-788-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number199713
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: NOAMAN SANNI
Title or Position: OWNER
Credential: MD
Phone: 315-788-6070