Provider Demographics
NPI:1831187871
Name:MITRA, AMITABHA (MD)
Entity type:Individual
Prefix:
First Name:AMITABHA
Middle Name:
Last Name:MITRA
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1907
Practice Address - Country:US
Practice Address - Phone:570-326-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023302E2086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009709710001Medicaid
PA121789Medicare PIN
C30758Medicare UPIN