Basic Information
| Provider Information | |||||||||
| NPI: | 1447233879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOYLAN | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Practice Location | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 07/14/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301041177 | MI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | A77372 | 01 | MI | HAP | OTHER | 3406334131 | 01 | MI | BCBSM INDIVIDUAL ID | OTHER | 4366812 | 01 | MI | AETNA | OTHER | DM041177 | 01 | MI | BCBSM OTHER IDENTIFIER | OTHER | C5868 | 01 | MI | MCARE | OTHER | DM041177 | 01 | MI | BCBSM LICENSE NUMBER | OTHER | 34104505 | 01 | MI | RAILROAD MEDICARE | OTHER | 4973523 | 05 | MI | MEDICAID |