Provider Demographics
NPI:1457678641
Name:ANTIC, ANICA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANICA
Middle Name:
Last Name:ANTIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANICA
Other - Middle Name:
Other - Last Name:NIKOLIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06504-0902
Mailing Address - Country:US
Mailing Address - Phone:203-397-8000
Mailing Address - Fax:203-389-1540
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-444-5100
Practice Address - Fax:860-444-3709
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049493207ZP0102X
PAMD 436081207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008031615Medicaid
CT400047282Medicare PIN