Provider Demographics
NPI:1831193697
Name:SMITH, LESLIE L (DO)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 STATE ROAD 415
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6012
Mailing Address - Country:US
Mailing Address - Phone:407-322-8645
Mailing Address - Fax:407-324-7311
Practice Address - Street 1:2400 STATE ROAD 415
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6012
Practice Address - Country:US
Practice Address - Phone:407-322-8645
Practice Address - Fax:407-324-7311
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47084OtherBC/BS
FL172745OtherWELLCARE MEDICARE
FL257196000Medicaid
FL01114593OtherAMERIGROUP
FL172745OtherWELLCARE MEDICARE
FL257196000Medicaid