Provider Demographics
NPI:1316289960
Name:M B KAYANI PHYSICIAN PC
Entity type:Organization
Organization Name:M B KAYANI PHYSICIAN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-788-6070
Mailing Address - Street 1:1815 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9406
Mailing Address - Country:US
Mailing Address - Phone:315-788-6070
Mailing Address - Fax:315-788-1950
Practice Address - Street 1:12 MAIN ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-2007
Practice Address - Country:US
Practice Address - Phone:315-261-4287
Practice Address - Fax:315-261-4319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:M B KAYANI PHYSICIAN PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-21
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03424311Medicaid