Provider Demographics
NPI:1043408958
Name:EDWARD J MOYLAN OD PC
Entity Type:Organization
Organization Name:EDWARD J MOYLAN OD PC
Other - Org Name:NORTH SHORE ADVANCED EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOYLAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:631-642-2020
Mailing Address - Street 1:537 PATCHOGUE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1006
Mailing Address - Country:US
Mailing Address - Phone:631-642-2020
Mailing Address - Fax:631-642-3938
Practice Address - Street 1:537 PATCHOGUE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1006
Practice Address - Country:US
Practice Address - Phone:631-642-2020
Practice Address - Fax:631-642-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004922-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCAWWP1Medicare PIN