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
StateLicense IDTaxonomies
NV10630208VP0014X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500786Medicaid
NVH95435Medicare UPIN
NV100500786Medicaid