Healthcare Provider Details

I. General information

NPI: 1851386551
Provider Name (Legal Business Name): MARK J STOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

IV. Provider business mailing address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-1530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01069517A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number62383
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036080105
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number62383
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: