Provider Demographics
NPI:1861562985
Name:VANDER LUGT, MARK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:VANDER LUGT
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 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:7TH FLOOR C.S. MOTT CHILDRENS HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4257
Practice Address - Country:US
Practice Address - Phone:734-936-9814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4465132080P0207X
MI43010941302080P0207X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics