| Entity Name: | NEUROLOGY CONSULTANTS OF SOUTH FLORIDA, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 23 Aug 2004 (20 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 15 Oct 2018 (6 years ago) |
| Document Number: | P04000121660 |
| FEI/EIN Number | 20-1528804 |
| Address: | 4160 W. 16TH AVE.,, SUITE#100, HIALEAH, FL 33012 |
| Mail Address: | 4160 W. 16TH AVE.,, SUITE#100, HIALEAH, FL 33012 |
| ZIP code: | 33012 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1417017823 | 2006-12-08 | 2010-07-19 | PO BOX 126629, HIALEAH, FL, 330121610, US | 4160 W 16TH AVE, SUITE 100, HIALEAH, FL, 330125853, US | |||||||||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 305-826-5655 |
| Fax | 3058265598 |
Authorized person
| Name | DR. MARTHA BUSTAMANTE |
| Role | PRESIDENT |
| Phone | 3058265655 |
Taxonomy
| Taxonomy Code | 2084N0008X - Neuromuscular Medicine (Psychiatry & Neurology) Physician |
| License Number | ME58534 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| License Number | ME58534 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084N0402X - Neurology with Special Qualifications in Child Neurology Physician |
| License Number | ME58534 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 2084P0005X - Neurodevelopmental Disabilities Physician |
| License Number | ME58534 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD FL |
| Number | 99443 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ZOMERFELD, RAYMOND J | Agent | 355 Alhambra Circle, Suite 1100, CORAL GABLES, FL 33134 |
| Name | Role | Address |
|---|---|---|
| BUSTAMANTE, MARTHA | President | 4160 W. 16TH AVE., #100, HIALEAH, FL 33012 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000119343 | MARTHA BUSTAMANTE MD | ACTIVE | 2020-09-14 | 2025-12-31 | No data | 4160 WEST 16TH AVE, STE 100, HIALEAH, FL, 33012 |
| G08310900258 | MARTHA BUSTAMANTE MD | EXPIRED | 2008-11-05 | 2013-12-31 | No data | 4160 WEST 16TH AVE, SUITE#100, HIALEAH, FL, 33012 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2019-03-13 | 355 Alhambra Circle, Suite 1100, CORAL GABLES, FL 33134 | No data |
| REINSTATEMENT | 2018-10-15 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| REINSTATEMENT | 2017-10-30 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2017-10-30 | ZOMERFELD, RAYMOND J | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2010-04-29 | 4160 W. 16TH AVE.,, SUITE#100, HIALEAH, FL 33012 | No data |
| CHANGE OF MAILING ADDRESS | 2010-04-29 | 4160 W. 16TH AVE.,, SUITE#100, HIALEAH, FL 33012 | No data |
| CANCEL ADM DISS/REV | 2005-10-11 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J18000769463 | TERMINATED | 1000000804144 | DADE | 2018-11-15 | 2028-11-21 | $ 604.78 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, MIAMI SERVICE CENTER, 8175 NW 12TH ST STE 119, DORAL FL331261828 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-01-23 |
| ANNUAL REPORT | 2022-02-09 |
| ANNUAL REPORT | 2021-01-13 |
| ANNUAL REPORT | 2020-09-14 |
| ANNUAL REPORT | 2019-03-13 |
| REINSTATEMENT | 2018-10-15 |
| REINSTATEMENT | 2017-10-30 |
| ANNUAL REPORT | 2016-01-17 |
| ANNUAL REPORT | 2015-01-13 |
Date of last update: 05 Jan 2025
Sources: Florida Department of State
