Provider Demographics
NPI:1205878386
Name:STOUT, ALAN (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:STOUT
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 1:612 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-4610
Mailing Address - Country:US
Mailing Address - Phone:706-980-9975
Mailing Address - Fax:
Practice Address - Street 1:612 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-4610
Practice Address - Country:US
Practice Address - Phone:706-980-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026664207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000320526GMedicaid
GA000320526HMedicaid
GAP00282948OtherRAILROAD MEDICARE
GA000320526FMedicaid
TN4130194OtherBCBS OF TENNESSEE