Provider Demographics
NPI:1114246667
Name:MALYUTINA, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MALYUTINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SW 73RD ST
Mailing Address - Street 2:BOX 69
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:786-662-5465
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:BOX 69
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:786-662-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine