Provider Demographics
NPI:1326133976
Name:STOUT-BAUTISTA, KATHERINE MARJORIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARJORIE
Last Name:STOUT-BAUTISTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:MARJORIE
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1033 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3107
Mailing Address - Country:US
Mailing Address - Phone:415-482-6826
Mailing Address - Fax:415-482-6726
Practice Address - Street 1:1033 3RD ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3107
Practice Address - Country:US
Practice Address - Phone:415-482-6826
Practice Address - Fax:415-482-6726
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT-12944-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist