Healthcare Provider Details

I. General information

NPI: 1730121880
Provider Name (Legal Business Name): DOUGLAS R VANDERJAGT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 S PUTNAM ST
WILLIAMSTON MI
48895-1623
US

IV. Provider business mailing address

3955 PATIENT CARE DR
LANSING MI
48911-4299
US

V. Phone/Fax

Practice location:
  • Phone: 517-655-3515
  • Fax: 855-476-0189
Mailing address:
  • Phone: 517-374-7600
  • Fax: 885-480-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101013545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: