Provider Demographics
NPI:1972647493
Name:WARREN C STOUT MD A MEDICAL CORP
Entity Type:Organization
Organization Name:WARREN C STOUT MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-202-6204
Mailing Address - Street 1:800 E. COLORADO BLVD.
Mailing Address - Street 2:SUITE 260
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101
Mailing Address - Country:US
Mailing Address - Phone:626-449-6494
Mailing Address - Fax:626-449-0813
Practice Address - Street 1:800 E. COLORADO BLVD.
Practice Address - Street 2:SUITE 260
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-449-6494
Practice Address - Fax:626-449-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9540699880207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10850Medicare ID - Type UnspecifiedMEDICARE GROUP #