Healthcare Provider Details

I. General information

NPI: 1265435382
Provider Name (Legal Business Name): KITTI K OUTLAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/21/2006

III. Provider practice location address

3715 DAUPHIN ST STE 6A
MOBILE AL
36608-1774
US

IV. Provider business mailing address

3715 DAUPHIN ST STE 6A
MOBILE AL
36608-1774
US

V. Phone/Fax

Practice location:
  • Phone: 251-414-1333
  • Fax: 351-414-3006
Mailing address:
  • Phone: 251-414-1333
  • Fax: 351-414-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number00018171
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number00018171
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: