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General NPI Number Information
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NPI Number | 1457681371
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Entity Type | Organization
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Legal Business Name | PAUL J SUPER OD A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/29/2009
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Last Update Date | 03/03/2016
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Provider Practice Location Address
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Address Line | 11777 SAN VICENTE BLVD #130
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City | LOS ANGELES
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State | CA
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Zip | 90049-5011
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Country | US
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Telephone | 310-820-2020
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Fax | 310-820-1884
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Provider Business Mailing Address
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Address Line | 11777 SAN VICENTE BLVD #130
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City | LOS ANGELES
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State | CA
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Zip | 90049-5011
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Country | US
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Telephone | 310-820-2020
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Fax | 310-820-1884
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. PAUL J SUPER
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Credential | O.D.
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Telephone | 310-820-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | OPT8867T
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | OP8867TPG
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | OP8867TPG
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 152WL0500X
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Taxonomy Name | Low Vision Rehabilitation Optometrist
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License Number | OP8867TPG
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | OP8867TPG
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OP8867TPG
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License Number State | CA
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