Provider Demographics
NPI:1194998286
Name:BRIANT G. MOYLES D.P.M., P.A.
Entity type:Organization
Organization Name:BRIANT G. MOYLES D.P.M., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, PA
Authorized Official - Phone:321-255-3338
Mailing Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2946
Mailing Address - Country:US
Mailing Address - Phone:321-723-3500
Mailing Address - Fax:321-723-1945
Practice Address - Street 1:1310 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5300
Practice Address - Country:US
Practice Address - Phone:321-255-3338
Practice Address - Fax:321-253-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041009800Medicaid
FL72224OtherBCBS
FL72224Medicare PIN
FL0528660002Medicare NSC