Provider Demographics
NPI:1366603318
Name:VANDERVLIET, JON (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:VANDERVLIET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 HOGBACK RD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9750
Mailing Address - Country:US
Mailing Address - Phone:734-786-2317
Mailing Address - Fax:734-786-4977
Practice Address - Street 1:2006 HOGBACK RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-786-2317
Practice Address - Fax:734-786-4977
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092851207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH17604112OtherMEDICARE PTAN
MI4301092851OtherMICHIGAN LICENSE
MI1366603318Medicaid