Provider Demographics
NPI:1184707903
Name:STOUTIN, SHERRY D (MD)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:D
Last Name:STOUTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-298-4521
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-298-4521
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5696208D00000X
WAMD00040032208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA69378OtherWA LABOR & INDUSTRIES
WA8118655Medicaid
ID80094290Medicare ID - Type UnspecifiedID RR MEDICARE
WA8118655Medicaid
IDB56921Medicare UPIN