Provider Demographics
NPI:1649499807
Name:SUPER, PAUL JONATHAN (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JONATHAN
Last Name:SUPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:J
Other - Last Name:SUPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:11696 SAN VICENTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5104
Mailing Address - Country:US
Mailing Address - Phone:310-820-2020
Mailing Address - Fax:310-820-1884
Practice Address - Street 1:11696 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5104
Practice Address - Country:US
Practice Address - Phone:310-820-2020
Practice Address - Fax:310-820-1884
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP8867TPG152WC0802X
CAOPT8867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP8867Medicare ID - Type UnspecifiedOPTOMETRIST