Provider Demographics
NPI: | 1891792743 |
---|---|
Name: | OUTLAW, EDWARD MICHAEL (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | EDWARD |
Middle Name: | MICHAEL |
Last Name: | OUTLAW |
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: | 10926 MERRITT DR |
Mailing Address - Street 2: | |
Mailing Address - City: | STOCKTON |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95219-7192 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-592-0713 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4505 PRECISSI LN STE A |
Practice Address - Street 2: | |
Practice Address - City: | STOCKTON |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95207-6240 |
Practice Address - Country: | US |
Practice Address - Phone: | 209-425-3815 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-07 |
Last Update Date: | 2019-06-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NV | 10630 | 208VP0014X, 2081P2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NV | 100500786 | Medicaid | |
NV | H95435 | Medicare UPIN | |
NV | 100500786 | Medicaid |