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"FirstLineMailingAddress": "PO BOX 31502",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "415-645-4525",
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"FirstLinePracticeLocationAddress": "23141 MOULTON PKWY STE 109",
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"PracticeLocationAddressCityName": "LAGUNA HILLS",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "949-272-0007",
"PracticeLocationAddressFaxNumber": "949-272-0006",
"EnumerationDate": "03/20/2017",
"LastUpdateDate": "08/01/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "05/16/2019",
"NPIReactivationDate": "05/22/2019",
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GLAZER",
"AuthorizedOfficialFirstName": "DEVON",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "DPM",
"AuthorizedOfficialTelephoneNumber": "949-272-0007",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "332B00000X",
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},
{
"TaxonomyCode": "213ES0103X",
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}
]
},
"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."
}
}
}
}