Provider Demographics
NPI:1487658399
Name:STOUT, KIMBER M (MD)
Entity Type:Individual
Prefix:
First Name:KIMBER
Middle Name:M
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:PO BOX 8387
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87198-8387
Mailing Address - Country:US
Mailing Address - Phone:505-841-1000
Mailing Address - Fax:505-843-2853
Practice Address - Street 1:2085 S PACHECO ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5473
Practice Address - Country:US
Practice Address - Phone:505-984-8012
Practice Address - Fax:505-988-2612
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0705207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51384795Medicaid
D04937Medicare UPIN
NM349402201Medicare PIN