Healthcare Provider Details

I. General information

NPI: 1013179548
Provider Name (Legal Business Name): CHANCELLOR FOLSOM GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7540 W UNIVERSITY AVE
GAINESVILLE FL
32607-7609
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0915
US

V. Phone/Fax

Practice location:
  • Phone: 352-647-9700
  • Fax: 352-525-4902
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-558-6185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMT192846
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberME124154
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: