| Entity Name: | JACOB JOSEPH, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 15 Jan 1986 (39 years ago) |
| Document Number: | H94315 |
| FEI/EIN Number | 630830168 |
| Address: | JACOB JOSEPH, 7024 portmarnock pl, BRADENTON, FL, 34202, US |
| Mail Address: | JACOB JOSEPH, 7024 portmarnock pl, lakewood ranch, FL, 34202, US |
| ZIP code: | 34202 |
| County: | Manatee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1184730962 | 2006-08-22 | 2007-11-26 | PO BOX 15179, BRADENTON, FL, 342805179, US | 2820 MANATEE AVE W, BRADENTON, FL, 342054237, US | |||||||||||||||||||||||||
|
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| Phone | +1 941-746-1662 |
| Fax | 9417474394 |
Authorized person
| Name | DR. JACOB JOSEPH |
| Role | OWNER |
| Phone | 9417461662 |
Taxonomy
| Taxonomy Code | 207XX0005X - Sports Medicine (Orthopaedic Surgery) Physician |
| License Number | ME46458 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 40943 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JOSEPH JACOB M | Agent | JACOB JOSEPH, lakewood ranch, FL, 34202 |
| Name | Role | Address |
|---|---|---|
| JOSEPH, JACOB | Director | JACOB JOSEPH, lakewood ranch, FL, 34202 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| REINSTATEMENT | 2010-07-21 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2009-09-25 | No data | No data |
| EVENT CONVERTED TO NOTES | 1986-05-06 | No data | No data |
| NAME CHANGE AMENDMENT | 1986-04-29 | JACOB JOSEPH, M.D., P.A. | No data |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
