Healthcare Provider Details

I. General information

NPI: 1679770994
Provider Name (Legal Business Name): CHARLES EMMET STOUT JR. MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

700 E REDLANDS BLVD # 714
REDLANDS CA
92373-6109
US

V. Phone/Fax

Practice location:
  • Phone: 951-338-4910
  • Fax: 833-996-0004
Mailing address:
  • Phone: 951-338-4910
  • Fax: 833-996-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA100577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: