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General NPI Number Information
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NPI Number | 1760731517
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Entity Type | Individual
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Provider Name | EVAN J STOUT O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/06/2012
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Last Update Date | 10/31/2016
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Provider Practice Location Address
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Address Line | 450 5TH AVE SW
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City | MAGEE
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State | MS
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Zip | 39111-3960
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Country | US
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Telephone | 601-849-5004
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Fax |
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Provider Business Mailing Address
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Address Line | 710 MAIN ST SUITE 20
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City | COLLINS
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State | MS
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Zip | 39428-6292
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Country | US
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Telephone | 601-837-5102
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 859
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License Number State | MS
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