Provider Demographics
NPI:1295890317
Name:STOUT, RANDALL C (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:C
Last Name:STOUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3600 CAPITAL AVE SW
Mailing Address - Street 2:STE 203
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9393
Mailing Address - Country:US
Mailing Address - Phone:269-979-6383
Mailing Address - Fax:269-979-6381
Practice Address - Street 1:3600 CAPITAL AVE SW
Practice Address - Street 2:STE 203
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9393
Practice Address - Country:US
Practice Address - Phone:269-979-6383
Practice Address - Fax:269-979-6381
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRS045322207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3158180Medicaid
MIRS048655OtherLICENSE
MI383224959100Medicaid
MI0831634OtherPHP
MIRS048655OtherLICENSE
MI0831634OtherPHP
MI1041770001Medicare ID - Type Unspecified