{
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"FirstLineMailingAddress": "3158 BANCROFT DR UNIT 1",
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"MailingAddressStateName": "CA",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "408-681-8831",
"MailingAddressFaxNumber": "858-328-4833",
"FirstLinePracticeLocationAddress": "4730 PALM AVE STE 214",
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"PracticeLocationAddressCityName": "LA MESA",
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"PracticeLocationAddressTelephoneNumber": "408-681-8831",
"PracticeLocationAddressFaxNumber": "858-328-4833",
"EnumerationDate": "09/10/2025",
"LastUpdateDate": "09/10/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MARTIN",
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"AuthorizedOfficialNameSuffix": "JR.",
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"AuthorizedOfficialTelephoneNumber": "408-681-8831",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "106H00000X",
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}