Provider Demographics
NPI:1467765107
Name:VANDERLUGT, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
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 1:926 WASHINGTON AVE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7725
Mailing Address - Country:US
Mailing Address - Phone:616-393-0166
Mailing Address - Fax:
Practice Address - Street 1:602 MICHIGAN AVE
Practice Address - Street 2:BOVEN BIRTH CENTER
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4918
Practice Address - Country:US
Practice Address - Phone:616-393-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096386208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics