Provider Demographics
NPI:1417160508
Name:VANDERLAAN, BURTON F (MD)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:F
Last Name:VANDERLAAN
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 1:5769 CHAROLAIS DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8703
Mailing Address - Country:US
Mailing Address - Phone:616-805-4459
Mailing Address - Fax:
Practice Address - Street 1:5769 CHAROLAIS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8703
Practice Address - Country:US
Practice Address - Phone:616-805-4459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057480207RX0202X
MI4301093441207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42734Medicare UPIN