{
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"FirstLineMailingAddress": "PO BOX 770754",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WINTER GARDEN",
"MailingAddressStateName": "FL",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": "352-663-8530",
"FirstLinePracticeLocationAddress": "3900 LAKE CENTER DR STE A1",
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"PracticeLocationAddressCityName": "MOUNT DORA",
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"PracticeLocationAddressTelephoneNumber": "525-627-5903",
"PracticeLocationAddressFaxNumber": "352-663-8530",
"EnumerationDate": "06/17/2016",
"LastUpdateDate": "02/25/2025",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "213ES0103X",
"TaxonomyName": "Foot & Ankle Surgery Podiatrist",
"LicenseNumber": "PO4048",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}