MEDICARE: DR. ADAM PAUL WIRA OD

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	152W00000X	Optometrist	2019021345	MO

General Provider Information

NPI Number	:	1518527860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAM PAUL WIRA OD

Provider Business Mailing Address
First Line	:	122 S COUNTY CENTER WAY STE A
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-1092
Country	:	US
Telephone Number	:	847-666-7650
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 S COUNTY CENTER WAY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-1089
Country	:	US
Telephone Number	:	314-416-7588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	08/05/2019

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