Provider Demographics
NPI:1730121880
Name:VANDERJAGT, DOUGLAS R (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:VANDERJAGT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4299
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:517-999-4018
Practice Address - Street 1:839 S PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1623
Practice Address - Country:US
Practice Address - Phone:517-655-3515
Practice Address - Fax:855-476-0189
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1000922OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI200000000943OtherPHP FAMILYCARE
MI1000922OtherMCLAREN HEALTH ADVANTAGE
MI4218345Medicaid
MI4835895Medicaid
MI1000922OtherMCLAREN HEALTH PLAN-MEDICAID
MI110205373OtherRAILROAD MEDICARE
MI1153302705OtherBCBS/BCN
MI7256209OtherAETNA
MI0M21440018OtherMEDICARE ADVANTAGE
MI200000000943OtherPHP
MIM21440018Medicare PIN
MI1000922OtherMCLAREN HEALTH PLAN-COMMERCIAL