{
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"FirstLineMailingAddress": "117 HARMON AVENUE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PANAMA CITY",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32401",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "850-819-4989",
"MailingAddressFaxNumber": "601-984-5110",
"FirstLinePracticeLocationAddress": "2407 RUTH HENTZ AVENUE",
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"PracticeLocationAddressCityName": "PANAMA CITY",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "850-522-5022",
"PracticeLocationAddressFaxNumber": "601-984-5110",
"EnumerationDate": "05/17/2018",
"LastUpdateDate": "07/26/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "06/23/2023",
"NPIReactivationDate": "07/25/2023",
"GenderCode": "M",
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"AuthorizedOfficialCredential": null,
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208600000X",
"TaxonomyName": "Surgery Physician",
"LicenseNumber": "ME162052",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}