Provider Demographics
NPI:1417915380
Name:KANZER, GORDON K (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:K
Last Name:KANZER
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 1:420 LIBBEY INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3134
Mailing Address - Country:US
Mailing Address - Phone:781-331-9880
Mailing Address - Fax:
Practice Address - Street 1:3 CEDARHILL PARK DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2226
Practice Address - Country:US
Practice Address - Phone:508-888-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA748172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
J11737Medicare PIN
F04260Medicare UPIN