Healthcare Provider Details

I. General information

NPI: 1164917621
Provider Name (Legal Business Name): JOHNNY SUN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1278 TOWN CENTRE DR STE 155
EAGAN MN
55123-6404
US

IV. Provider business mailing address

1278 TOWN CENTRE DR STE 155
EAGAN MN
55123-6404
US

V. Phone/Fax

Practice location:
  • Phone: 612-851-0208
  • Fax: 651-686-2940
Mailing address:
  • Phone: 612-851-0208
  • Fax: 651-686-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3997
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: