Basic Information
Provider Information | |||||||||
NPI: | 1316930688 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOUT | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | MARK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4801 S CLIFF AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | MO | ||||||||
PostalCode: | 640557015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164781230 | ||||||||
FaxNumber: | 8164784413 | ||||||||
Practice Location | |||||||||
Address1: | 11500 GRANADA ST | ||||||||
Address2: | DISCOVER VISION CENTERS | ||||||||
City: | LEAWOOD | ||||||||
State: | KS | ||||||||
PostalCode: | 662111453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164781230 | ||||||||
FaxNumber: | 8163506980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2005 | ||||||||
LastUpdateDate: | 04/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD108395 | MO | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 0429147 | KS | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207WX0107X | 04-29147 | KS | N |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 180041349 | 01 |   | RAILROAD MEDICARE | OTHER | 180041348 | 01 |   | RAILROAD MEDICARE | OTHER |