Provider Demographics
NPI:1063893717
Name:MOYNIHAN, MATTHEW J (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:MOYNIHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8081 INNOVATION PARK DR STE 500
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-7040
Practice Address - Fax:571-472-7041
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA264407390200000X
VA0101271565208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program