{
"Npi": {
"NPI": "1407115835",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "GONG",
"FirstName": "BO",
"MiddleName": null,
"NamePrefix": "MR.",
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "ZHAO",
"OtherFirstName": "JACK",
"OtherMiddleName": null,
"OtherNamePrefix": "DR.",
"OtherNameSuffix": null,
"OtherCredential": "DR. JACK",
"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "2579 OAK ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "KISSIMMEE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "34744-4946",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "407-288-4865",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "6559 N WICKHAM RD # C-103",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MELBOURNE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32940-2052",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "407-861-6966",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/04/2012",
"LastUpdateDate": "02/04/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "225700000X",
"TaxonomyName": "Massage Therapist",
"LicenseNumber": "MA68483",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
},
{
"TaxonomyCode": "390200000X",
"TaxonomyName": "Student in an Organized Health Care Education/Training Program",
"LicenseNumber": "MA68483",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
}
]
},
"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."
}
}
}
}