Healthcare Provider Details

I. General information

NPI: 1730203548
Provider Name (Legal Business Name): WATERTOWN MEDICAL OPTICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 STATE STREET
WATERTOWN NY
13601
US

IV. Provider business mailing address

1815 STATE STREET
WATERTOWN NY
13601
US

V. Phone/Fax

Practice location:
  • Phone: 315-786-8064
  • Fax: 315-788-1950
Mailing address:
  • Phone: 315-786-8064
  • Fax: 315-788-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT0053871
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2060481
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateNULL

VIII. Authorized Official

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