Provider Demographics
NPI:1356444509
Name:LICATA, ANITA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
Last Name:LICATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:GOODRICH
Other - Last Name:LICATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:354 MOUNTAIN VIEW DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5988
Mailing Address - Country:US
Mailing Address - Phone:802-658-8624
Mailing Address - Fax:802-860-4919
Practice Address - Street 1:354 MOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 300
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5988
Practice Address - Country:US
Practice Address - Phone:802-864-0192
Practice Address - Fax:802-860-4919
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008753207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F61578Medicare UPIN
LIVN0673Medicare ID - Type Unspecified