Provider Demographics
NPI:1336145663
Name:JUDELLE, JESSE (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:JUDELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:850-216-0100
Mailing Address - Fax:850-216-0180
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01092OtherUNIVERSAL HEALTH CARE
FL051174900Medicaid
FL00000OtherMULTIPLAN NETWORK
FL00000OtherUNITED HC
FL00000OtherBC BS OF FLORIDA
FL00000OtherSOUTHCARE NETWORK
FL0000OtherEVOUTIONS HC
FL00000OtherBEECH ST/CAPP CARE
FL00000OtherUNITED HC
FL00000OtherSOUTHCARE NETWORK