{
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"FirstLineMailingAddress": "2600 LAKE LUCIEN DR STE 180",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MAITLAND",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32751-7235",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "407-875-2080",
"MailingAddressFaxNumber": "407-875-0518",
"FirstLinePracticeLocationAddress": "16800NW 2ND AVENUE",
"SecondLinePracticeLocationAddress": "SUITE 204",
"PracticeLocationAddressCityName": "NORTH MIAMI",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressTelephoneNumber": "305-652-8600",
"PracticeLocationAddressFaxNumber": "305-652-3139",
"EnumerationDate": "06/06/2008",
"LastUpdateDate": "06/06/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DECLUE",
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"AuthorizedOfficialTitle": "DIRECTOR PROVIDER SERVICES",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "407-875-2080",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}