Provider Demographics
NPI:1245240761
Name:STOUTIN, LYNDAL E (MD)
Entity Type:Individual
Prefix:
First Name:LYNDAL
Middle Name:E
Last Name:STOUTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2841 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4719
Mailing Address - Country:US
Mailing Address - Phone:208-743-9712
Mailing Address - Fax:208-298-0212
Practice Address - Street 1:2841 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4719
Practice Address - Country:US
Practice Address - Phone:208-743-9712
Practice Address - Fax:208-298-0212
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5693208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E69416Medicare UPIN
1123876Medicare ID - Type Unspecified