Basic Information
| Provider Information | |||||||||
| NPI: | 1235193111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FATIGATI | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
| Address2: | 165 SHERMAN DRIVE | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489405 | ||||||||
| FaxNumber: | 8027484540 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058558537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023343520 | ||||||||
| FaxNumber: | 8023343512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 420010948 | VT | Y | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1011893 | 05 | VT | MEDICAID | I43919 | 01 | MEDICARE | OTHER |