Healthcare Provider Details

I. General information

NPI: 1295969947
Provider Name (Legal Business Name): DENISE ANNE SMITH M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MEDCREST DR
CRESTVIEW FL
32536-6440
US

IV. Provider business mailing address

332 MEDCREST DR
CRESTVIEW FL
32536-6440
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-0032
  • Fax: 850-682-0034
Mailing address:
  • Phone: 850-682-0032
  • Fax: 850-682-0034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA131396
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME129104
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number95608
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101269130
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD0089278
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35.099103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: