Provider Demographics
NPI:1750328241
Name:MITIAS, ABRAHAM S (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:S
Last Name:MITIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3970
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-3970
Mailing Address - Country:US
Mailing Address - Phone:304-346-4400
Mailing Address - Fax:304-346-0704
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-346-4400
Practice Address - Fax:304-346-0704
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35097037207WX0107X
WV22677208600000X, 207WX0107X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009024Medicaid
OH2766412Medicaid
KY7100019950Medicaid
P00429863Medicare PIN
WV3810009024Medicaid