Provider Demographics
NPI:1114913183
Name:CANZLER, GORDON PAUL (DO)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:PAUL
Last Name:CANZLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NE ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7464
Mailing Address - Country:US
Mailing Address - Phone:503-665-9144
Mailing Address - Fax:503-665-6404
Practice Address - Street 1:400 NE ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7464
Practice Address - Country:US
Practice Address - Phone:503-665-9144
Practice Address - Fax:503-665-6404
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR205823Medicaid
OR08WFBBRAMedicare ID - Type Unspecified
OR205823Medicaid