Basic Information
| Provider Information | |||||||||
| NPI: | 1972797348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | IVELISSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D.; MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4440 FRUITVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342321926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413660134 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328047133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072461946 | ||||||||
| FaxNumber: | 8558955749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ACN897 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7586 | PR | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0901X | MPH | PR | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 208D00000X | ACN897 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2542 | 01 | FL | DIPLOMATE AMERICAN BOARD OF SEXOLOGY | OTHER | 020108900 | 05 | FL | MEDICAID | FS57XXXXX | 01 | FL | DEA | OTHER | XX86 | 01 | PR | MD LICENSE | OTHER | XS57XXXXX | 01 | PR | DEA BUPRENORPHINE & OPIOS DEPENDENCE TREATMENT | OTHER | ACN 897 | 01 | FL | MD LICENSE | OTHER |