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General NPI Number Information
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NPI Number | 1972797348
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Entity Type | Individual
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Provider Name | WANDA IVELISSE SMITH M.D.; MPH
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Gender | Female
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Dates
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Enumeration Date | 08/29/2007
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1301 W COLONIAL DR
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City | ORLANDO
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State | FL
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Zip | 32804-7133
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Country | US
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Telephone | 407-246-1946
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Fax | 855-895-5749
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Provider Business Mailing Address
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Address Line | 4440 FRUITVILLE RD
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City | SARASOTA
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State | FL
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Zip | 34232-1926
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Country | US
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Telephone | 941-366-0134
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ACN897
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 7586
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License Number State | PR
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Taxonomy #3
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number | MPH
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License Number State | PR
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Taxonomy #4
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ACN897
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License Number State | FL
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