| Entity Name: | DIXITKUMAR N MODI MD PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 05 Aug 2019 (6 years ago) |
| Document Number: | P19000061551 |
| FEI/EIN Number | 84-2682380 |
| Address: | 3003 TRASONA DRIVE, MELBOURNE, FL, 32940, US |
| Mail Address: | 3003 TRASONA DRIVE, MELBOURNE, FL, 32940, US |
| ZIP code: | 32940 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1962059493 | 2019-08-20 | 2024-02-23 | 3003 TRASONA DR, MELBOURNE, FL, 329407670, US | 4350 N ATLANTIC AVE, COCOA BEACH, FL, 329313656, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 321-613-5352 |
| Fax | 3216135356 |
| Phone | +1 334-327-9530 |
Authorized person
| Name | DR. DIXITKUMAR NAVINCHANDRA MODI |
| Role | OWNER |
| Phone | 3343279530 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 104790300 |
| State | FL |
| Issuer | MEDICAL LICENSE |
| Number | ME133520 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DIXITKUMAR N. MODI, MD, PA 401(K) PLAN AND TRUST | 2022 | 842682380 | 2023-10-11 | DIXITKUMAR N. MODI, MD, PA | 5 | |||||||||||||
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| DIXITKUMAR N. MODI, MD, PA 401(K) PLAN AND TRUST | 2021 | 842682380 | 2022-10-10 | DIXITKUMAR N. MODI, MD, PA | 5 | |||||||||||||
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| Name | Role | Address |
|---|---|---|
| MODI DIXITKUMAR N | Agent | 3003 TRASONA DRIVE, MELBOURNE, FL, 32940 |
| Name | Role | Address |
|---|---|---|
| MODI DIXITKUMAR N | President | 3003 TRASONA DRIVE, MELBOURNE, FL, 32940 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000008321 | PREMIER MEDICAL CLINIC | ACTIVE | 2020-01-17 | 2025-12-31 | No data | 3003 TRASONA DRIVE, MELBOURNE, FL, 32940 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-03 |
| ANNUAL REPORT | 2023-07-12 |
| ANNUAL REPORT | 2022-01-30 |
| ANNUAL REPORT | 2021-03-14 |
| ANNUAL REPORT | 2020-01-07 |
| Domestic Profit | 2019-08-05 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
