Healthcare Provider Details

I. General information

NPI: 1063588424
Provider Name (Legal Business Name): EDWARD JOHN MOYLAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 PATCHOGUE ROAD
PORT JEFFERSON STATION NY
11776
US

IV. Provider business mailing address

15 OLD HOMESTEAD RD
PORT JEFFERSON NY
11777-1108
US

V. Phone/Fax

Practice location:
  • Phone: 631-642-2020
  • Fax: 631-642-3938
Mailing address:
  • Phone: 631-476-7099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004922-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: