{
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"EIN": null,
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"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "3926 NEW VISION DR",
"SecondLineMailingAddress": "BLDG. H",
"MailingAddressCityName": "FORT WAYNE",
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"MailingAddressPostalCode": "46845-1712",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "260-373-9700",
"MailingAddressFaxNumber": "260-373-9740",
"FirstLinePracticeLocationAddress": "2708 GUILFORD ST",
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"PracticeLocationAddressStateName": "IN",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "260-355-3900",
"PracticeLocationAddressFaxNumber": "260-355-3079",
"EnumerationDate": "12/08/2005",
"LastUpdateDate": "03/24/2016",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
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"TaxonomyName": "Family Medicine Physician",
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"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}