Provider Demographics
NPI:1417488131
Name:STOUT, SEAN CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:CRAIG
Last Name:STOUT
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 1:901 N CURTIS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1339
Mailing Address - Country:US
Mailing Address - Phone:208-378-0080
Mailing Address - Fax:
Practice Address - Street 1:901 N CURTIS RD STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1339
Practice Address - Country:US
Practice Address - Phone:208-378-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021058208000000X
MO2020009905207K00000X
390200000X
IDM-16211207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program