| Entity Name: | DEERFIELD BEACH MEDICAL CLINIC, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 25 Jun 2002 (23 years ago) |
| Document Number: | P02000069715 |
| FEI/EIN Number | 043689393 |
| Address: | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL, 33073 |
| Mail Address: | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL, 33073 |
| ZIP code: | 33073 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1275732414 | 2007-07-17 | 2009-01-09 | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL, 33073, US | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL, 33073, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 954-725-8808 |
| Fax | 9547258818 |
Authorized person
| Name | DR. NAM QUOC NGUYEN |
| Role | PRESIDENT |
| Phone | 9547258808 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | OS0008287 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | HUMANA PROVIDER NUMBER |
| Number | 000107864 |
| Issuer | MEDICAID |
| Number | H78725 |
| State | FL |
| Issuer | MEDICAID |
| Number | 264678100 |
| State | FL |
| Issuer | BLUE CROSS BLE SHIELD PRO |
| Number | 51382 |
| State | FL |
| Issuer | NEIGBORHOOD HEALTH PROVID |
| Number | 43340 |
| Issuer | AETNA PRIVIDER NUMBER |
| Number | 145360 |
| Issuer | AVMED PROVIDER NUMBER |
| Number | 289806 |
| Issuer | OXFORD HEALTH PLANS PROVI |
| Number | P2789955 |
| Name | Role | Address |
|---|---|---|
| NGUYEN NAM Q | Agent | 9631 SAVONA WINDS DRIVE, DELRAY BEACH, FL, 33446 |
| Name | Role | Address |
|---|---|---|
| NGUYEN NAM Q | President | 9631 SAVONA WINDS DRIVE, DELRAY BEACH, FL, 33446 |
| Name | Role | Address |
|---|---|---|
| NGUYEN NAM Q | Secretary | 9631 SAVONA WINDS DRIVE, DELRAY BEACH, FL, 33446 |
| Name | Role | Address |
|---|---|---|
| NGUYEN NAM Q | Treasurer | 9631 SAVONA WINDS DRIVE, DELRAY BEACH, FL, 33446 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2009-04-01 | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL 33073 | No data |
| CHANGE OF MAILING ADDRESS | 2009-04-01 | 5300 W. HILLSBORO BLVD., SUITE 216, COCONUT CREEK, FL 33073 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2003-05-01 | 9631 SAVONA WINDS DRIVE, DELRAY BEACH, FL 33446 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-21 |
| ANNUAL REPORT | 2023-03-23 |
| ANNUAL REPORT | 2022-04-20 |
| ANNUAL REPORT | 2021-04-19 |
| ANNUAL REPORT | 2020-05-01 |
| ANNUAL REPORT | 2019-03-15 |
| ANNUAL REPORT | 2018-04-20 |
| ANNUAL REPORT | 2017-07-03 |
| ANNUAL REPORT | 2016-03-29 |
| ANNUAL REPORT | 2015-04-23 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
