Basic Information
| Provider Information | |||||||||
| NPI: | 1932195914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOYNIHAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101033952 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7374101 | 05 | VA | MEDICAID |