Provider Demographics
NPI:1710418942
Name:OUTHAY, MALENA
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:
Last Name:OUTHAY
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 1:1411 E 31ST ST
Mailing Address - Street 2:QIC 22123
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:QIC 22123
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA162504207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine