Provider Demographics
NPI:1487659868
Name:VREDEVOOGD, LISA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:VREDEVOOGD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:TANTTILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:205 W 29TH ST
Mailing Address - Street 2:SUITE 50
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-6973
Mailing Address - Country:US
Mailing Address - Phone:616-796-9995
Mailing Address - Fax:616-796-9998
Practice Address - Street 1:205 W 29TH ST
Practice Address - Street 2:SUITE 50
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-6973
Practice Address - Country:US
Practice Address - Phone:616-796-9995
Practice Address - Fax:616-796-9998
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071619207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG75703Medicare UPIN