Provider Demographics
NPI:1174593933
Name:CHODOSH, LANCE IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:IVAN
Last Name:CHODOSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 W NEWBERRY RD
Mailing Address - Street 2:#201
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2586
Mailing Address - Country:US
Mailing Address - Phone:352-372-3360
Mailing Address - Fax:352-372-3776
Practice Address - Street 1:4340 W NEWBERRY RD
Practice Address - Street 2:#201
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2586
Practice Address - Country:US
Practice Address - Phone:352-372-3360
Practice Address - Fax:352-372-3776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00212402083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58395Medicare UPIN