Provider Demographics
NPI:1760731517
Name:STOUT, EVAN J (OD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:J
Last Name:STOUT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 MAIN ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428-6292
Mailing Address - Country:US
Mailing Address - Phone:601-837-5102
Mailing Address - Fax:
Practice Address - Street 1:450 5TH AVE SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3960
Practice Address - Country:US
Practice Address - Phone:601-849-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist