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General NPI Number Information
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NPI Number | 1518527860
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Entity Type | Individual
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Provider Name | ADAM PAUL WIRA OD
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Gender | Male
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Dates
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Enumeration Date | 06/18/2019
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Last Update Date | 08/05/2019
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Provider Practice Location Address
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Address Line | 122 S COUNTY CENTER WAY
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City | SAINT LOUIS
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State | MO
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Zip | 63129-1089
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Country | US
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Telephone | 314-416-7588
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Fax |
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Provider Business Mailing Address
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Address Line | 122 S COUNTY CENTER WAY STE A
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City | SAINT LOUIS
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State | MO
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Zip | 63129-1092
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Country | US
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Telephone | 847-666-7650
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2019021345
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License Number State | MO
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