Provider Demographics
NPI:1518982552
Name:STOUT, JOHN PATRICK (M D)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
Last Name:STOUT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E BOULDER ST
Mailing Address - Street 2:LABORATORY, MEMORIAL HOSPITAL
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-365-5808
Mailing Address - Fax:719-365-6908
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:LABORATORY, MEMORIAL HOSPITAL
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5808
Practice Address - Fax:719-365-6908
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO29669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01296698Medicaid
COP00367433Medicare PIN
CO01296698Medicaid
COC807076Medicare PIN