{
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"FirstLineMailingAddress": "6415 LAKE WORTH RD STE 102",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GREENACRES",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33463-3009",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "561-331-0808",
"MailingAddressFaxNumber": "561-237-6034",
"FirstLinePracticeLocationAddress": "120 JFK DR STE 120",
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"PracticeLocationAddressCityName": "ATLANTIS",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "561-331-0808",
"PracticeLocationAddressFaxNumber": "561-594-0880",
"EnumerationDate": "03/15/2007",
"LastUpdateDate": "06/01/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IBARROLA",
"AuthorizedOfficialFirstName": "AGUSTIN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "561-331-0808",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208600000X",
"TaxonomyName": "Surgery Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}