| Entity Name: | NASSER MOUKADDEM, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 28 Jul 1999 (26 years ago) |
| Date of dissolution: | 17 Feb 2024 (a year ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 17 Feb 2024 (a year ago) |
| Document Number: | P99000067159 |
| FEI/EIN Number | 593590539 |
| Address: | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL, 33711 |
| Mail Address: | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL, 33711 |
| ZIP code: | 33711 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1831220235 | 2007-03-08 | 2013-12-04 | 4226 CENTRAL AVE, ST PETERSBURG, FL, 337111140, US | 4226 CENTRAL AVE, ST PETERSBURG, FL, 337111140, US | |||||||||||||||||||||||||||||||
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| Phone | +1 727-321-3915 |
| Fax | 7273280975 |
Authorized person
| Name | NASSER MOUKADDEM |
| Role | PRESIDENT |
| Phone | 7273213915 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | ME71447 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 260638100 |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | 110189691 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MY CENTRAL PRIMARY CARE 401(K) PROFIT SHARING PLAN | 2022 | 593590539 | 2023-06-28 | NASSER MOUKADDEM, M.D. P.A. | 8 | |||||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2023-06-28 |
| Name of individual signing | DR. NASSER MOUKADDEM |
| Valid signature | Filed with authorized/valid electronic signature |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 7273213915 |
| Plan sponsor’s DBA name | MY CENTRAL PRIMARY CARE |
| Plan sponsor’s address | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL, 33711 |
Signature of
| Role | Plan administrator |
| Date | 2022-10-14 |
| Name of individual signing | DR. NASSER MOUKADDEM |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 7273213915 |
| Plan sponsor’s DBA name | MY CENTRAL PRIMARY CARE |
| Plan sponsor’s address | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL, 33711 |
Signature of
| Role | Plan administrator |
| Date | 2022-06-28 |
| Name of individual signing | DR. NASSER MOUKADDEM |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| ARSENAULT KENNETH G | Agent | 10225 ULMERTON ROAD, LARGO, FL, 33771 |
| Name | Role | Address |
|---|---|---|
| MOUKADDEM NASSER M | Director | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL, 33711 |
| BARKOV MARINA M | Director | 4226 CENTRAL AVE, ST. PETERSBURG, FL, 33711 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2024-02-17 | No data | No data |
| NAME CHANGE AMENDMENT | 2007-08-21 | NASSER MOUKADDEM, M.D., P.A. | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2004-01-25 | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL 33711 | No data |
| CHANGE OF MAILING ADDRESS | 2004-01-25 | 4226 CENTRAL AVENUE, ST. PETERSBURG, FL 33711 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2004-01-25 | 10225 ULMERTON ROAD, SUITE 2, LARGO, FL 33771 | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2024-02-17 |
| ANNUAL REPORT | 2023-02-13 |
| ANNUAL REPORT | 2022-01-30 |
| ANNUAL REPORT | 2021-01-24 |
| ANNUAL REPORT | 2020-01-19 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-01-14 |
| ANNUAL REPORT | 2017-01-15 |
| ANNUAL REPORT | 2016-01-24 |
| ANNUAL REPORT | 2015-01-12 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
