{
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"FirstLineMailingAddress": "PO BOX 1068",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PERTH AMBOY",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "08862-1068",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "732-442-6020",
"MailingAddressFaxNumber": "732-442-1995",
"FirstLinePracticeLocationAddress": "400 STATE ST.",
"SecondLinePracticeLocationAddress": "SUITE 2",
"PracticeLocationAddressCityName": "PERTH AMBOY",
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"PracticeLocationAddressTelephoneNumber": "732-442-6020",
"PracticeLocationAddressFaxNumber": "732-442-1995",
"EnumerationDate": "10/03/2006",
"LastUpdateDate": "09/11/2013",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GUILLEN",
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"AuthorizedOfficialCredential": "M.D",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "MA56159",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}