Provider Demographics
NPI:1871781534
Name:FAROOK J KIDWAI MD PC
Entity type:Organization
Organization Name:FAROOK J KIDWAI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAROOK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIDWAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-755-6099
Mailing Address - Street 1:1340 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4541
Mailing Address - Country:US
Mailing Address - Phone:315-755-6099
Mailing Address - Fax:
Practice Address - Street 1:1340 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4541
Practice Address - Country:US
Practice Address - Phone:315-755-6099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI140410168174400000X
207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty