Provider Demographics
NPI:1457681371
Name:PAUL J SUPER OD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PAUL J SUPER OD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-820-2020
Mailing Address - Street 1:11777 SAN VICENTE BLVD
Mailing Address - Street 2:#130
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5011
Mailing Address - Country:US
Mailing Address - Phone:310-820-2020
Mailing Address - Fax:310-820-1884
Practice Address - Street 1:11777 SAN VICENTE BLVD
Practice Address - Street 2:#130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5011
Practice Address - Country:US
Practice Address - Phone:310-820-2020
Practice Address - Fax:310-820-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP8867TPG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X
CAOPT8867T302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty