| Entity Name: | OKALOOSA CARDIOLOGY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 08 Nov 1991 (33 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 04 Nov 2002 (22 years ago) |
| Document Number: | S92998 |
| FEI/EIN Number | 59-3093454 |
| Address: | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 |
| Mail Address: | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 |
| ZIP code: | 32539 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1144270240 | 2006-05-11 | 2011-08-25 | 129 E REDSTONE AVE, SUITE A, CRESTVIEW, FL, 325395350, US | 129 E REDSTONE AVE, SUITE A, CRESTVIEW, FL, 325395350, US | |||||||||||||||||||||||
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| Phone | +1 850-682-7212 |
Authorized person
| Name | DONNA M GIBSON |
| Role | BILLING MANAGER |
| Phone | 8506827212 |
Taxonomy
| Taxonomy Code | 207RC0000X - Cardiovascular Disease Physician |
| Is Primary | Yes |
| Taxonomy Code | 2086S0129X - Vascular Surgery Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 258928100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Al-Dehneh, Anthony S, DO | Agent | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 |
| Name | Role | Address |
|---|---|---|
| Al-Dehneh, Anthony S, DO | President | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 |
| Name | Role | Address |
|---|---|---|
| YOUSSEF, GEORGE A, MD | Vice President | 129 EAST REDSTONE AVENUE, SUITE A CRESTVIEW, FL 32539 |
| Name | Role | Address |
|---|---|---|
| Zarate, Juan C, MD | Secretary | 129 EAST REDSTONE AVENUE, SUITE A CRESTVIEW, FL 32539 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G19000077824 | OKALOOSA HEART & VASCULAR CENTER | ACTIVE | 2019-07-18 | 2029-12-31 | No data | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL, 32539 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-03-11 | Al-Dehneh, Anthony S, DO | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2008-10-06 | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2008-01-29 | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 | No data |
| CHANGE OF MAILING ADDRESS | 2008-01-29 | 129 EAST REDSTONE AVENUE, SUITE A, CRESTVIEW, FL 32539 | No data |
| REINSTATEMENT | 2002-11-04 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2002-10-04 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-11 |
| ANNUAL REPORT | 2023-01-25 |
| ANNUAL REPORT | 2022-03-09 |
| ANNUAL REPORT | 2021-04-08 |
| ANNUAL REPORT | 2020-06-09 |
| ANNUAL REPORT | 2019-04-03 |
| ANNUAL REPORT | 2018-01-17 |
| ANNUAL REPORT | 2017-01-10 |
| ANNUAL REPORT | 2016-01-25 |
| ANNUAL REPORT | 2015-01-27 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
