Healthcare Provider Details

I. General information

NPI: 1912282708
Provider Name (Legal Business Name): JEFFREY EDWARD STOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SILCLINIC, PHILIPPINES RD.
UKARUMPA EHP
444
PG

IV. Provider business mailing address

SIL CLINIC PO BOX 1(222)
UKARUMPA EHP
444
PG

V. Phone/Fax

Practice location:
  • Phone: 0116755374411
  • Fax: 0116755373555
Mailing address:
  • Phone: 0116755374411
  • Fax: 0116755373555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA34138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: