Healthcare Provider Details

I. General information

NPI: 1457681371
Provider Name (Legal Business Name): PAUL J SUPER OD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11777 SAN VICENTE BLVD #130
LOS ANGELES CA
90049-5011
US

IV. Provider business mailing address

11777 SAN VICENTE BLVD #130
LOS ANGELES CA
90049-5011
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-2020
  • Fax: 310-820-1884
Mailing address:
  • Phone: 310-820-2020
  • Fax: 310-820-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberOPT8867T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOP8867TPG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOP8867TPG
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOP8867TPG
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOP8867TPG
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP8867TPG
License Number StateCA

VIII. Authorized Official

Name: DR. PAUL J SUPER
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 310-820-2020