Provider Demographics
NPI:1235133653
Name:VANDER WOUDE, DOUGLAS LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:LEE
Last Name:VANDER WOUDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:220 LYON ST NW
Mailing Address - Street 2:STE 700
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2210
Mailing Address - Country:US
Mailing Address - Phone:616-451-4500
Mailing Address - Fax:616-451-9077
Practice Address - Street 1:220 LYON ST NW
Practice Address - Street 2:STE 700
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2210
Practice Address - Country:US
Practice Address - Phone:616-451-4500
Practice Address - Fax:616-451-9077
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407024208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3483009Medicaid
MI16082010Medicare ID - Type Unspecified
MIG04311Medicare UPIN