Healthcare Provider Details

I. General information

NPI: 1700846797
Provider Name (Legal Business Name): GAVAN DAVID MOYNIHAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 E MAIN ST
BAY SHORE NY
11706-8404
US

IV. Provider business mailing address

332 E MAIN ST
BAY SHORE NY
11706-8404
US

V. Phone/Fax

Practice location:
  • Phone: 631-666-0500
  • Fax: 631-666-0503
Mailing address:
  • Phone: 631-666-0500
  • Fax: 631-666-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number122511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: