Provider Demographics
NPI:1053314393
Name:STOUT, KEITH B (M D)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
Last Name:STOUT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4612
Mailing Address - Country:US
Mailing Address - Phone:409-813-1677
Mailing Address - Fax:409-730-1399
Practice Address - Street 1:3480 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4612
Practice Address - Country:US
Practice Address - Phone:409-813-1677
Practice Address - Fax:409-730-1399
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9428207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137850712Medicaid
TX137850712Medicaid