{
"Npi": {
"NPI": "1770868416",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "T.R. MATIONG MD PA",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "10201 STATE ROAD 52",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HUDSON",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "34669-3071",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "727-857-1818",
"MailingAddressFaxNumber": "727-857-1609",
"FirstLinePracticeLocationAddress": "10201 STATE ROAD 52",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HUDSON",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "34669-3071",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "727-857-1818",
"PracticeLocationAddressFaxNumber": "727-857-1609",
"EnumerationDate": "10/13/2011",
"LastUpdateDate": "07/08/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MATIONG",
"AuthorizedOfficialFirstName": "TEODULO",
"AuthorizedOfficialMiddleName": "R",
"AuthorizedOfficialTitle": "PRACTITIONER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "727-857-1818",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "302F00000X",
"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}