Healthcare Provider Details

I. General information

NPI: 1043552854
Provider Name (Legal Business Name): M B KAYANI PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HOSPITAL DR
MASSENA NY
13662-1009
US

IV. Provider business mailing address

1815 STATE ST
WATERTOWN NY
13601-9407
US

V. Phone/Fax

Practice location:
  • Phone: 315-705-6508
  • Fax: 315-705-6511
Mailing address:
  • Phone: 315-788-6070
  • Fax: 315-788-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
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