{
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "9451 CYPRESS LAKE DR",
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"MailingAddressCityName": "FORT MYERS",
"MailingAddressStateName": "FL",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "239-481-7322",
"MailingAddressFaxNumber": "239-481-0151",
"FirstLinePracticeLocationAddress": "1700 PERIWINKLE WAY STE 7",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "239-481-7322",
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"EnumerationDate": "07/31/2024",
"LastUpdateDate": "06/10/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CERAVOLO",
"AuthorizedOfficialFirstName": "JUSTIN",
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"AuthorizedOfficialCredential": "PHARM D",
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"Taxonomies": {
"Taxonomy": [
{
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"PrimaryTaxonomySwitch": "N"
},
{
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}
]
},
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}
}