Provider Demographics
NPI:1336593839
Name:STOUT, DEREK RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RUSSELL
Last Name:STOUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-0488
Mailing Address - Country:US
Mailing Address - Phone:855-968-8233
Mailing Address - Fax:866-502-1008
Practice Address - Street 1:810 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9617
Practice Address - Country:US
Practice Address - Phone:855-968-8233
Practice Address - Fax:866-502-1008
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH21104207L00000X
NC2022-01044207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology