{
"Npi": {
"NPI": "1477946820",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ADVANCED WOUND CARE OF NORTH FLORIDA, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "108 PRINCE PHILLIP DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ST AUGUSTINE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32092-1746",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "813-380-1492",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "13500 SUTTON PARK DR S",
"SecondLinePracticeLocationAddress": "SUITE 403",
"PracticeLocationAddressCityName": "JACKSONVILLE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32224-5251",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "904-493-3390",
"PracticeLocationAddressFaxNumber": "904-493-3395",
"EnumerationDate": "03/10/2015",
"LastUpdateDate": "03/10/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LAGOUTARIS",
"AuthorizedOfficialFirstName": "JOHN",
"AuthorizedOfficialMiddleName": "DEMETRIOS",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DPM",
"AuthorizedOfficialTelephoneNumber": "813-380-1492",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "213ES0103X",
"TaxonomyName": "Foot & Ankle Surgery Podiatrist",
"LicenseNumber": "PO3240",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "213ES0131X",
"TaxonomyName": "Foot Surgery Podiatrist",
"LicenseNumber": "PO3240",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "213EP1101X",
"TaxonomyName": "Primary Podiatric Medicine Podiatrist",
"LicenseNumber": "PO3240",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}