{
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"FirstLineMailingAddress": "PO BOX 1770",
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"MailingAddressCityName": "LA MESA",
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"MailingAddressPostalCode": "91944-1770",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "619-464-1165",
"MailingAddressFaxNumber": "619-567-1011",
"FirstLinePracticeLocationAddress": "1287 FULTON RD",
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"PracticeLocationAddressCityName": "SANTA ROSA",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressTelephoneNumber": "707-888-5808",
"PracticeLocationAddressFaxNumber": "707-577-8315",
"EnumerationDate": "02/25/2013",
"LastUpdateDate": "03/07/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MEDVIN",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": "LEE",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "707-888-5808",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "A0736012",
"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."
}
}
}
}