Healthcare Provider Details

I. General information

NPI: 1831700798
Provider Name (Legal Business Name): MUYCHI TIMOTHY VANG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 N GARDEN
BLOOMINGTON MN
55425-5519
US

IV. Provider business mailing address

304 N GARDEN
BLOOMINGTON MN
55425-5519
US

V. Phone/Fax

Practice location:
  • Phone: 952-858-8410
  • Fax: 952-858-8408
Mailing address:
  • Phone: 952-858-8410
  • Fax: 952-858-8408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3695
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: