Healthcare Provider Details

I. General information

NPI: 1750328241
Provider Name (Legal Business Name): ABRAHAM S MITIAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 LAIDLEY ST SUITE 301
CHARLESTON WV
25301-1619
US

IV. Provider business mailing address

PO BOX 3970
CHARLESTON WV
25339-3970
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-4400
  • Fax: 304-346-0704
Mailing address:
  • Phone: 304-346-4400
  • Fax: 304-346-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number35097037
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number22677
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number22677
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: