Healthcare Provider Details

I. General information

NPI: 1114913183
Provider Name (Legal Business Name): GORDON PAUL CANZLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE ROBERTS AVE
GRESHAM OR
97030-7464
US

IV. Provider business mailing address

400 NE ROBERTS AVE
GRESHAM OR
97030-7464
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-9144
  • Fax: 503-665-6404
Mailing address:
  • Phone: 503-665-9144
  • Fax: 503-665-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO15150
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier205823
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: