| Entity Name: | KIDSVILLE PEDIATRICS I, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 04 Jan 1999 (26 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 22 Jul 2011 (14 years ago) |
| Document Number: | P99000001057 |
| FEI/EIN Number | 593551592 |
| Mail Address: | P.O. BOX 452223, KISSIMMEE, FL, 34745 |
| Address: | 2201 NORTH BLVD. WEST, DAVENPORT, FL, 33837 |
| ZIP code: | 33837 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1780658294 | 2006-02-14 | 2022-10-07 | 2201 NORTH BLVD W, DAVENPORT, FL, 338378990, US | 2201 NORTH BLVD W, DAVENPORT, FL, 338378990, US | |||||||||||||||||||||||||||||||
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| Phone | +1 863-419-0688 |
| Fax | 8634199547 |
Authorized person
| Name | MR. VICTOR M. PANTOJA JR. |
| Role | ADMINISTRATOR |
| Phone | 8634190688 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME-0074421 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 265713900 |
| State | FL |
| Issuer | MEDICARE |
| Number | GV270A |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PANTOJA VICTOR MJr. | Agent | 2201 North Blvd West, Devenport, FL, 33837 |
| Name | Role | Address |
|---|---|---|
| GONZALEZ FRANCELIS IDr. | Chief Executive Officer | PO BOX 452223, KISSIMMEE, FL, 34745 |
| Name | Role | Address |
|---|---|---|
| PANTOJA VICTOR MJr. | President | P.O. BOX 452223, KISSIMMEE, FL, 34745 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2021-01-27 | 2201 North Blvd West, Devenport, FL 33837 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-03-03 | PANTOJA, VICTOR M., Jr. | No data |
| AMENDMENT | 2011-07-22 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2008-03-17 | 2201 NORTH BLVD. WEST, DAVENPORT, FL 33837 | No data |
| NAME CHANGE AMENDMENT | 2004-04-05 | KIDSVILLE PEDIATRICS I, P.A. | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2002-02-01 | 2201 NORTH BLVD. WEST, DAVENPORT, FL 33837 | 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: 02 Feb 2025
Sources: Florida Department of State
