Provider Demographics
NPI:1801946249
Name:LICATA, VINCENT D (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:D
Last Name:LICATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3133 PROFESSIONAL DR
Practice Address - Street 2:#20
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2463
Practice Address - Country:US
Practice Address - Phone:530-885-8821
Practice Address - Fax:530-885-6554
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G490900Medicaid
00G490900Medicare ID - Type Unspecified
CA00G490903Medicare PIN
CA00G490900Medicaid