Provider Demographics
NPI:1467638338
Name:RONALD L VANDERLUGT MD
Entity Type:Organization
Organization Name:RONALD L VANDERLUGT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDERLUGT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-383-1110
Mailing Address - Street 1:1717 SHAFFER ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1625
Mailing Address - Country:US
Mailing Address - Phone:269-383-1110
Mailing Address - Fax:269-383-1103
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:SUITE 207
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1625
Practice Address - Country:US
Practice Address - Phone:269-383-1110
Practice Address - Fax:269-383-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046147207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1120200001Medicare NSC