{
"Npi": {
"NPI": "1891991642",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "FAKHRAIE",
"FirstName": "KEIKO",
"MiddleName": "SATO",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "D.O.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "12361 W BOLA DR STE 109",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SURPRISE",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85378-9021",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "623-227-1000",
"MailingAddressFaxNumber": "623-227-2000",
"FirstLinePracticeLocationAddress": "2501 N STOCKTON HILL RD STE 108",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "KINGMAN",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "86401-4140",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "928-255-5050",
"PracticeLocationAddressFaxNumber": "888-571-5897",
"EnumerationDate": "06/26/2007",
"LastUpdateDate": "01/03/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207Q00000X",
"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": "005309",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}