| Name | Description | Type | Additional information |
|---|---|---|---|
| Doctor Name | string |
None. |
|
| Address1 | string |
None. |
|
| City | string |
None. |
|
| State | StateCodeEnum |
None. |
|
| Zip | string |
None. |
|
| Phone | string |
None. |
|
| Ext. | string |
None. |
|
| Fax | string |
None. |