Provider Demographics
NPI:1063588424
Name:MOYLAN, EDWARD JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:MOYLAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OLD HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1108
Mailing Address - Country:US
Mailing Address - Phone:631-476-7099
Mailing Address - Fax:
Practice Address - Street 1:537 PATCHOGUE ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-642-2020
Practice Address - Fax:631-642-3938
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004922-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCAWWP1Medicare UPIN
NYU17998Medicare UPIN
NYC41141Medicare ID - Type Unspecified