Provider Demographics
NPI:1235181215
Name:KIDWAI, FAROOK J (MD)
Entity Type:Individual
Prefix:DR
First Name:FAROOK
Middle Name:J
Last Name:KIDWAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:315-755-0226
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:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139481207T00000X
SD7577207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03579531Medicaid
NYJ400100074Medicare PIN