Prominent rivers include the Shag, the Waianakarua, the Kakanui and the Waitaki. The Kakanui Mountains form the principal cordillera, rising at their highest point, Mount Pisgah, to 1,643 metres (5,390 ft). These are separated from the lower, parallel Horse Range by the upper valleys of the Waianakarua and Shag rivers.
The large east-coast town of Oamaru serves as North Otago's main centre. Other towns and settlements in the region include Alma, Totara, Teschemakers, Reidston, Maheno, Kakanui, Herbert (also known as Otepopo), Waianakarua, Hampden, and Moeraki, all on or close to the coast south of Oamaru. The coastal plain north of Oamaru has the settlements of Hilderthorpe and Pukeuri.
Inland settlements include Weston, Ardgowan, Windsor, Five Forks, Peebles, Papakaio, Duntroon, Kurow (on the south bank of the Waitaki), Omarama, and Otematata.