Provider Demographics
NPI:1851351050
Name:HADDAD-LACLE, JUDELLA EDWINA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDELLA
Middle Name:EDWINA
Last Name:HADDAD-LACLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2377 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6983
Practice Address - Country:US
Practice Address - Phone:904-648-8090
Practice Address - Fax:904-648-8089
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3738787-00Medicaid
GA000569742BMedicaid
FLF38546Medicare UPIN
FL17823YMedicare PIN
GA000569742BMedicaid