| Entity Name: | KWABENA AYESU, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 15 Mar 2005 (20 years ago) |
| Last Event: | CANCEL ADM DISS/REV |
| Event Date Filed: | 04 Nov 2007 (17 years ago) |
| Document Number: | P05000038963 |
| FEI/EIN Number | 562500290 |
| Address: | 609 N Charles Richard Beall Blvd, DEBARY, FL, 32713, US |
| Mail Address: | 609 N Charles Richard Beall Blvd, DEBARY, FL, 32713, US |
| ZIP code: | 32713 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1659563146 | 2007-08-17 | 2008-06-19 | 86 SPRING VISTA DR, SUITE 100, DEBARY, FL, 327131818, US | 86 SPRING VISTA DR, SUITE 100, DEBARY, FL, 327131818, US | |||||||||||||||||||||||||||||
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| Phone | +1 386-774-6111 |
| Fax | 3867748111 |
Authorized person
| Name | KWABENA AYESU |
| Role | DOCTOR/OWNER |
| Phone | 3867746111 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 81108B |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | P00269607 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| AYESU KWABENA M | Agent | 609 N Charles Richard Beall Blvd, DEBARY, FL, 32713 |
| Name | Role | Address |
|---|---|---|
| AYESU KWABENA M | President | 332 N SPAULDING COVE, LAKE MARY, FL, 32746 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2017-04-10 | 609 N Charles Richard Beall Blvd, DEBARY, FL 32713 | No data |
| CHANGE OF MAILING ADDRESS | 2017-04-10 | 609 N Charles Richard Beall Blvd, DEBARY, FL 32713 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2017-04-10 | 609 N Charles Richard Beall Blvd, DEBARY, FL 32713 | No data |
| CANCEL ADM DISS/REV | 2007-11-04 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2007-09-14 | No data | No data |
| NAME CHANGE AMENDMENT | 2005-04-11 | KWABENA AYESU, M.D., P.A. | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-28 |
| ANNUAL REPORT | 2023-04-17 |
| ANNUAL REPORT | 2022-04-15 |
| ANNUAL REPORT | 2021-03-27 |
| ANNUAL REPORT | 2020-03-31 |
| ANNUAL REPORT | 2019-04-12 |
| ANNUAL REPORT | 2018-04-10 |
| ANNUAL REPORT | 2017-04-10 |
| ANNUAL REPORT | 2016-02-27 |
| ANNUAL REPORT | 2015-04-24 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
