Provider Demographics
NPI:1831700798
Name:VANG, MUYCHI TIMOTHY (OD)
Entity type:Individual
Prefix:
First Name:MUYCHI
Middle Name:TIMOTHY
Last Name:VANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 COMMERCE DR N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3122
Mailing Address - Country:US
Mailing Address - Phone:763-427-5474
Mailing Address - Fax:
Practice Address - Street 1:11217 COMMERCE DR N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3122
Practice Address - Country:US
Practice Address - Phone:763-427-5474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist