{
"Npi": {
"NPI": "1851419410",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WARLITO G ROLLOLAZO",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
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"OtherMiddleName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "809 W BANKHEAD HWY",
"SecondLineMailingAddress": "SUITE D",
"MailingAddressCityName": "VILLA RICA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30180-1520",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "770-456-9993",
"MailingAddressFaxNumber": "770-456-9949",
"FirstLinePracticeLocationAddress": "809 W BANKHEAD HWY",
"SecondLinePracticeLocationAddress": "SUITE D",
"PracticeLocationAddressCityName": "VILLA RICA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30180-1520",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-456-9993",
"PracticeLocationAddressFaxNumber": "770-456-9949",
"EnumerationDate": "03/26/2007",
"LastUpdateDate": "06/13/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROLLOLAZO",
"AuthorizedOfficialFirstName": "WARLITO",
"AuthorizedOfficialMiddleName": "G",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "770-456-9993",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208D00000X",
"TaxonomyName": "General Practice Physician",
"LicenseNumber": "17551",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"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."
}
}
}
}