Basic Information
| Provider Information | |||||||||
| NPI: | 1730121880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERJAGT | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3955 PATIENT CARE DR | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173747600 | ||||||||
| FaxNumber: | 5179994018 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 S PUTNAM ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488951623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176553515 | ||||||||
| FaxNumber: | 8554760189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101013545 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1000922 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | 200000000943 | 01 | MI | PHP FAMILYCARE | OTHER | 1000922 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 4218345 | 05 | MI | MEDICAID | 4835895 | 05 | MI | MEDICAID | 1000922 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER | 110205373 | 01 | MI | RAILROAD MEDICARE | OTHER | 1153302705 | 01 | MI | BCBS/BCN | OTHER | 7256209 | 01 | MI | AETNA | OTHER | 0M21440018 | 01 | MI | MEDICARE ADVANTAGE | OTHER | 200000000943 | 01 | MI | PHP | OTHER |