Provider Demographics
NPI:1912282708
Name:STOUT, JEFFREY EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:STOUT
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:SIL CLINIC
Mailing Address - Street 2:PO BOX 1(222)
Mailing Address - City:UKARUMPA
Mailing Address - State:EHP
Mailing Address - Zip Code:444
Mailing Address - Country:PG
Mailing Address - Phone:011675-537-4411
Mailing Address - Fax:011675-537-3555
Practice Address - Street 1:SILCLINIC, PHILIPPINES RD.
Practice Address - Street 2:
Practice Address - City:UKARUMPA
Practice Address - State:EHP
Practice Address - Zip Code:444
Practice Address - Country:PG
Practice Address - Phone:011675-537-4411
Practice Address - Fax:011675-537-3555
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine