{
"Npi": {
"NPI": "1962871608",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LAKES DERMATOLOGY, PA",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2732 IRVING AVE S",
"SecondLineMailingAddress": "SUITE 110",
"MailingAddressCityName": "MINNEAPOLIS",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55408-1049",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "612-387-4627",
"MailingAddressFaxNumber": "612-377-9713",
"FirstLinePracticeLocationAddress": "14305 SOUTHCROSS DR W",
"SecondLinePracticeLocationAddress": "SUITE 110",
"PracticeLocationAddressCityName": "BURNSVILLE",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55306-7009",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "612-387-4627",
"PracticeLocationAddressFaxNumber": "612-377-9713",
"EnumerationDate": "09/23/2015",
"LastUpdateDate": "09/23/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "AHMED-SAUCEDO",
"AuthorizedOfficialFirstName": "REHANA",
"AuthorizedOfficialMiddleName": "LEILA",
"AuthorizedOfficialTitle": "DERMATOLOGIST, PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD, PHD",
"AuthorizedOfficialTelephoneNumber": "612-387-4627",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": "51837",
"LicenseNumberStateCode": "MN",
"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."
}
}
}
}