Healthcare Provider Details

I. General information

NPI: 1174593933
Provider Name (Legal Business Name): LANCE IVAN CHODOSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 W NEWBERRY RD #201
GAINESVILLE FL
32607-2586
US

IV. Provider business mailing address

4340 W NEWBERRY RD #201
GAINESVILLE FL
32607-2586
US

V. Phone/Fax

Practice location:
  • Phone: 352-372-3360
  • Fax: 352-372-3776
Mailing address:
  • Phone: 352-372-3360
  • Fax: 352-372-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberME0021240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: