Provider Demographics
NPI:1265467476
Name:VANDERLUGT, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:VANDERLUGT
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:3988 W STATE ROAD 10
Practice Address - Street 2:
Practice Address - City:WHEATFIELD
Practice Address - State:IN
Practice Address - Zip Code:46392-9251
Practice Address - Country:US
Practice Address - Phone:219-987-3581
Practice Address - Fax:219-987-7137
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038324A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100086440AMedicaid
IN100086440AMedicaid
IN390380CMedicare ID - Type Unspecified