Provider Demographics
NPI:1659332302
Name:MOYLAN, BRIAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:MOYLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2246 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072-3559
Practice Address - Country:US
Practice Address - Phone:804-642-6171
Practice Address - Fax:804-642-5656
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015521R53Medicare PIN
VA080084303Medicare PIN
VAB69643Medicare UPIN
VA1659332302Medicaid