| Entity Name: | BRANDON DERMATOLOGY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 30 Dec 2002 (22 years ago) |
| Document Number: | P03000000044 |
| FEI/EIN Number | 050548764 |
| Address: | 405 W BLOOMINGDALE AVE, BRANDON, FL, 33511-7401, US |
| Mail Address: | 405 W BLOOMINGDALE AVE, BRANDON, FL, 33511-7401, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1760504682 | 2007-04-03 | 2008-09-19 | 405 W BLOOMINGDALE AVE, BRANDON, FL, 335117401, US | 405 W BLOOMINGDALE AVE, BRANDON, FL, 335117401, US | |||||||||||||||||||||||||
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| Phone | +1 813-662-3376 |
| Fax | 8136623009 |
Authorized person
| Name | ANDRES TOBON |
| Role | PRESIDENTPHYSICIAN |
| Phone | 8136623376 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| License Number | OS7868 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | AL785 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| TOBON ANDRES | Agent | 405 W BLOOMINGDALE AVE, BRANDON, FL, 335117401 |
| Name | Role | Address |
|---|---|---|
| TOBON ANDRES Dr. | President | 405 W BLOOMINGDALE AVE, BRANDON, FL, 335117401 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000124404 | DERMATOLOGY ON HENDERSON | ACTIVE | 2020-09-24 | 2025-12-31 | No data | 405 W BLOOMINGDALE AVE, BRANDON, FL, 33511 |
| G16000061638 | APOLLO BEACH DERMATOLOGY | ACTIVE | 2016-06-22 | 2026-12-31 | No data | 6424 N US HWY 41, APOLLO BEACH, FL, 33572 |
| G14000104375 | PLANT CITY DERMATOLOGY | ACTIVE | 2014-10-15 | 2029-12-31 | No data | 405 W BLOOMINGDALE AVE, BRANDON, FL, 33511 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-01-22 | 405 W BLOOMINGDALE AVE, BRANDON, FL 33511-7401 | No data |
| CHANGE OF MAILING ADDRESS | 2023-01-22 | 405 W BLOOMINGDALE AVE, BRANDON, FL 33511-7401 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-01-22 | 405 W BLOOMINGDALE AVE, BRANDON, FL 33511-7401 | No data |
| REGISTERED AGENT NAME CHANGED | 2003-03-07 | TOBON, ANDRES | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-14 |
| ANNUAL REPORT | 2023-01-22 |
| ANNUAL REPORT | 2022-02-03 |
| ANNUAL REPORT | 2021-01-12 |
| ANNUAL REPORT | 2020-01-20 |
| ANNUAL REPORT | 2019-02-14 |
| ANNUAL REPORT | 2018-02-06 |
| ANNUAL REPORT | 2017-01-16 |
| ANNUAL REPORT | 2016-02-03 |
| ANNUAL REPORT | 2015-02-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
