Healthcare Provider Details

I. General information

NPI: 1497756597
Provider Name (Legal Business Name): CHARLES WILLIAM STOUT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 PARKER BLVD SUITE 101
PUEBLO CO
81008-2285
US

IV. Provider business mailing address

3670 PARKER BLVD SUITE 101
PUEBLO CO
81008-2285
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-1544
  • Fax: 719-924-1593
Mailing address:
  • Phone: 719-564-1544
  • Fax: 719-924-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number33411
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number33411
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number48744
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: