Provider Demographics
NPI:1700846797
Name:MOYNIHAN, GAVAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GAVAN
Middle Name:DAVID
Last Name:MOYNIHAN
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 1:332 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8404
Mailing Address - Country:US
Mailing Address - Phone:631-666-0500
Mailing Address - Fax:631-666-0503
Practice Address - Street 1:332 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8404
Practice Address - Country:US
Practice Address - Phone:631-666-0500
Practice Address - Fax:631-666-0503
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122511207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00627990Medicaid
B19836Medicare UPIN
NYW07511Medicare ID - Type Unspecified