Healthcare Provider Details

I. General information

NPI: 1194070490
Provider Name (Legal Business Name): VIVIAN OWANIMEDU EKEMEZIE O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

9113 ASHLEY TER
BROOKLYN PARK MN
55443-1714
US

V. Phone/Fax

Practice location:
  • Phone: 612-338-4861
  • Fax: 612-333-8306
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3311
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: