Healthcare Provider Details

I. General information

NPI: 1447206495
Provider Name (Legal Business Name): NORTH COUNTRY NEUROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 WASHINGTON ST
WATERTOWN NY
13601-4541
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-9003
  • Fax: 315-782-9010
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: ABDUL LATIF
Title or Position: PRESIDENT
Credential: MD
Phone: 315-782-9003