{
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"FirstLineMailingAddress": "1330 CORTE DE PRIMAVERA",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "THOUSAND OAKS",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "805-428-1275",
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"FirstLinePracticeLocationAddress": "1330 CORTE DE PRIMAVERA",
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"PracticeLocationAddressFaxNumber": "805-523-2845",
"EnumerationDate": "09/20/2006",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "RANDOLPH",
"AuthorizedOfficialFirstName": "THEODORE",
"AuthorizedOfficialMiddleName": "ARTHUR",
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"AuthorizedOfficialCredential": "CCP",
"AuthorizedOfficialTelephoneNumber": "805-428-1275",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "246XC2903X",
"TaxonomyName": "Vascular Specialist/Technologist Cardiovascular",
"LicenseNumber": null,
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}