{
"Npi": {
"NPI": "1275912164",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BRONICO",
"FirstName": "JACKIE",
"MiddleName": "VALESCA RODRIGUEZ",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "M.D., MSC",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "RODRIGUEZ",
"OtherFirstName": "JACKIE",
"OtherMiddleName": "VALESCA",
"OtherNamePrefix": "DR.",
"OtherNameSuffix": null,
"OtherCredential": "M.D.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "34 E NEWTON ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BOSTON",
"MailingAddressStateName": "MA",
"MailingAddressPostalCode": "02118-1944",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "617-286-4565",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1035 CAMBRIDGE ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CAMBRIDGE",
"PracticeLocationAddressStateName": "MA",
"PracticeLocationAddressPostalCode": "02141-1057",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "617-286-4565",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/25/2015",
"LastUpdateDate": "01/29/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "TM109",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "390200000X",
"TaxonomyName": "Student in an Organized Health Care Education/Training Program",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "307533-01",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}