1194998286 NPI number — BRIANT G. MOYLES D.P.M., P.A.

Table of content: (NPI 1194998286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194998286 NPI number — BRIANT G. MOYLES D.P.M., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIANT G. MOYLES D.P.M., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194998286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-2946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-723-3500
Provider Business Mailing Address Fax Number:
321-723-1945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 W EAU GALLIE BLVD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-255-3338
Provider Business Practice Location Address Fax Number:
321-253-9643
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-255-3338

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 041009800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 72224 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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