Provider Demographics
NPI:1821592080
Name:STOUT, MARTY D
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:D
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 17TH PL SE APT 4
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5548
Mailing Address - Country:US
Mailing Address - Phone:202-491-6819
Mailing Address - Fax:
Practice Address - Street 1:2243 OXON HILL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20020
Practice Address - Country:US
Practice Address - Phone:202-491-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4311511744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management