Provider Demographics
NPI:1215059241
Name:LUGTHART, JAY ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ALLEN
Last Name:LUGTHART
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 1:4419 68TH ST SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9757
Practice Address - Country:US
Practice Address - Phone:616-457-4610
Practice Address - Fax:616-457-8750
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJL039848208D00000X, 207QG0300X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
114151PCOtherCCPPO, CHMO, MERCY HEALTH
121787OtherHEALR
152756OtherPHCS
4099325OtherAETNA
0107011492OtherBCBS
MIB44069OtherPRIORITY HEALTH
121787OtherHEALR
MIB44069OtherPRIORITY HEALTH