MEDICARE: DR. PAUL JONATHAN SUPER 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	152WC0802X	Corneal and Contact Management Optometrist	OP8867TPG	CA
2	152W00000X	Optometrist	OPT8867	CA

General Provider Information

NPI Number	:	1649499807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL JONATHAN SUPER OD

Provider Business Mailing Address
First Line	:	11696 SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5104
Country	:	US
Telephone Number	:	310-820-2020
Fax Number	:	310-820-1884

Provider Business Practice Location Address
First Line	:	11696 SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5104
Country	:	US
Telephone Number	:	310-820-2020
Fax Number	:	310-820-1884

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

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	12/23/2020

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