Provider Demographics
NPI:1558404152
Name:VANDERPLOEG, JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:VANDERPLOEG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4284 PLAINFIELD AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1612
Mailing Address - Country:US
Mailing Address - Phone:616-957-1600
Mailing Address - Fax:616-957-3925
Practice Address - Street 1:3205 28TH ST SE
Practice Address - Street 2:STE 1
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1695
Practice Address - Country:US
Practice Address - Phone:616-957-1600
Practice Address - Fax:616-957-3925
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004392152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist