Provider Demographics
NPI:1497855670
Name:PEDIATRIC ASSOCIATES OF WATERTOWN P.C.
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WATERTOWN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:F
Authorized Official - Last Name:VICTORIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-782-4391
Mailing Address - Street 1:PO BOX 6600
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6600
Mailing Address - Country:US
Mailing Address - Phone:315-782-4391
Mailing Address - Fax:315-788-8319
Practice Address - Street 1:18969 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5320
Practice Address - Country:US
Practice Address - Phone:315-782-4391
Practice Address - Fax:315-788-8319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty