Healthcare Provider Details

I. General information

NPI: 1487658399
Provider Name (Legal Business Name): KIMBER M STOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 S PACHECO ST SUITE A
SANTA FE NM
87505-5473
US

IV. Provider business mailing address

PO BOX 8387
ALBUQUERQUE NM
87198-8387
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8012
  • Fax: 505-988-2612
Mailing address:
  • Phone: 505-841-1000
  • Fax: 505-843-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2003-0705
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: