| Entity Name: | KIDSVILLE PEDIATRICS III, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 01 Jul 2004 (21 years ago) |
| Document Number: | P04000099541 |
| FEI/EIN Number | 731711024 |
| Address: | 1804 OAKLEY SEAVER DRIVE, SUITE -C, CLERMONT, FL, 34711 |
| Mail Address: | PO BOX 452223, KISSIMMEE, FL, 34745 |
| ZIP code: | 34711 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1215901723 | 2006-02-14 | 2022-10-07 | 1804 OAKLEY SEAVER BLVD, SUITE-C, CLERMONT, FL, 347111925, US | 1804 OAKLEY SEAVER BLVD, SUITE-C, CLERMONT, FL, 347111925, US | |||||||||||||||||||||||||||||||
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| Phone | +1 352-242-1021 |
| Fax | 3522421104 |
Authorized person
| Name | MR. VICTOR M. PANTOJA JR. |
| Role | ADMINISTRATOR |
| Phone | 3522421021 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME-0074421 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE |
| Number | FL206A |
| State | FL |
| Issuer | MEDICAID |
| Number | 001599400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PANTOJA VICTOR MJr. | Agent | 1804 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34741 |
| Name | Role | Address |
|---|---|---|
| GONZALEZ FRANCELIS IDr. | Chief Executive Officer | PO BOX 452223, KISSIMMEE, FL, 34745 |
| Name | Role | Address |
|---|---|---|
| PANTOJA VICTOR MJr. | President | PO BOX 452223, KISSIMMEE, FL, 34745 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000064806 | KIDSVILLE III FAMILY MEDICINE, PA | ACTIVE | 2012-06-28 | 2027-12-31 | No data | 1804 OAKLEY SEAVER DR SUITE C, SCENIC OAK CT, CLERMONT, FL, 34711 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2015-02-21 | PANTOJA , VICTOR M, Jr. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2010-03-22 | 1804 OAKLEY SEAVER DRIVE, SUITE -C, CLERMONT, FL 34741 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2005-01-19 | 1804 OAKLEY SEAVER DRIVE, SUITE -C, CLERMONT, FL 34711 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-04 |
| ANNUAL REPORT | 2023-02-17 |
| ANNUAL REPORT | 2022-02-22 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-02-17 |
| ANNUAL REPORT | 2019-02-09 |
| ANNUAL REPORT | 2018-03-10 |
| ANNUAL REPORT | 2017-02-09 |
| ANNUAL REPORT | 2016-03-04 |
| ANNUAL REPORT | 2015-02-21 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
