MEDICARE: PAUL J SUPER OD A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	OPT8867T	CA
2	152WV0400X	Vision Therapy Optometrist	OP8867TPG	CA
3	152WP0200X	Pediatric Optometrist	OP8867TPG	CA
4	152WL0500X	Low Vision Rehabilitation Optometrist	OP8867TPG	CA
5	152WC0802X	Corneal and Contact Management Optometrist	OP8867TPG	CA
6	152W00000X	Optometrist	OP8867TPG	CA

General Provider Information

NPI Number	:	1457681371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL J SUPER OD A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	11777 SAN VICENTE BLVD
Second Line	:	#130
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5011
Country	:	US
Telephone Number	:	310-820-2020
Fax Number	:	310-820-1884

Provider Business Practice Location Address
First Line	:	11777 SAN VICENTE BLVD
Second Line	:	#130
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5011
Country	:	US
Telephone Number	:	310-820-2020
Fax Number	:	310-820-1884

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. PAUL J SUPER
Credential	:	O.D.
Telephone Number	:	310-820-2020

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	03/03/2016

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