Provider Demographics
NPI:1730203548
Name:WATERTOWN MEDICAL OPTICAL PLLC
Entity type:Organization
Organization Name:WATERTOWN MEDICAL OPTICAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
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 STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-786-8064
Mailing Address - Fax:315-788-1950
Practice Address - Street 1:1815 STATE STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-786-8064
Practice Address - Fax:315-788-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT0053871152W00000X
NY2060481207W00000X
207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1276770001Medicare ID - Type Unspecified