Healthcare Provider Details

I. General information

NPI: 1508121567
Provider Name (Legal Business Name): DWAYNE LEE CHANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606
US

IV. Provider business mailing address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-5076
  • Fax: 706-475-6676
Mailing address:
  • Phone: 706-475-5076
  • Fax: 706-475-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74808
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number74808
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: