Provider Demographics
NPI:1518527860
Name:WIRA, ADAM PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:PAUL
Last Name:WIRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S COUNTY CENTER WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1092
Mailing Address - Country:US
Mailing Address - Phone:847-666-7650
Mailing Address - Fax:
Practice Address - Street 1:122 S COUNTY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1089
Practice Address - Country:US
Practice Address - Phone:314-416-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist