{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "GREGORY P. DERDERIAN D.O., P.C.",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"FirstLineMailingAddress": "6770 DIXIE HWY",
"SecondLineMailingAddress": "106A",
"MailingAddressCityName": "CLARKSTON",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48346-2087",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-922-9371",
"MailingAddressFaxNumber": "586-493-3828",
"FirstLinePracticeLocationAddress": "6770 DIXIE HWY",
"SecondLinePracticeLocationAddress": "106A",
"PracticeLocationAddressCityName": "CLARKSTON",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "248-922-9371",
"PracticeLocationAddressFaxNumber": "586-493-3828",
"EnumerationDate": "09/25/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DERDERIAN",
"AuthorizedOfficialFirstName": "GREGORY",
"AuthorizedOfficialMiddleName": "P",
"AuthorizedOfficialTitle": "PRESIDEENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "586-493-3175",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "2086S0129X",
"TaxonomyName": "Vascular Surgery Physician",
"LicenseNumber": "5101007182",
"LicenseNumberStateCode": "MI",
"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."
}
}
}
}