Provider Demographics
NPI:1740577170
Name:VANDERMOLEN, RONALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:VANDERMOLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1130 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1381
Mailing Address - Country:US
Mailing Address - Phone:248-642-4213
Mailing Address - Fax:
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:248-338-7171
Practice Address - Fax:248-858-3889
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB45070Medicare UPIN