Provider Demographics
NPI:1306834411
Name:STOUTENBURG, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:STOUTENBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:CR WOOD CANCER CENTER
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-6620
Practice Address - Fax:518-926-1954
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY225232207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02667792Medicaid
NYP00248124OtherRR MEDICARE
NYRA6754Medicare PIN
NYP00248124OtherRR MEDICARE