Provider Demographics
NPI:1972797348
Name:SMITH, WANDA IVELISSE (MD; MPH)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:IVELISSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD; MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 FRUITVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1926
Mailing Address - Country:US
Mailing Address - Phone:941-366-0134
Mailing Address - Fax:
Practice Address - Street 1:1301 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7133
Practice Address - Country:US
Practice Address - Phone:407-246-1946
Practice Address - Fax:855-895-5749
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN897207Q00000X, 208D00000X
PR7586207Q00000X
PRMPH2083P0901X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2542OtherDIPLOMATE AMERICAN BOARD OF SEXOLOGY
FL020108900Medicaid
PRXX86OtherMD LICENSE
FLACN 897OtherMD LICENSE
PRXS57XXXXXOtherDEA BUPRENORPHINE & OPIOS DEPENDENCE TREATMENT
FLACN 897OtherMD LICENSE
FLACN 897OtherMD LICENSE
OHOHIO UNIVOtherSEXUAL OFFENDER TREATMENT SPECIALIST
FLACN 897OtherMD LICENSE