GENERAL
Name
Medical School
Year of Graduation
National Provider Identifier(NPI)
License Number** DC
MD
VA
MEDICAL
Please check if you are certified and note the organization.
Primary Specialty
Certified?
2nd Specialty
Certified?
3rd Specialty
Certified?
4th Specialty
Certified?
FOREIGN
Please list the language(s)
in which you are sufficiently fluent to deal with patients on a
doctor/patient level or with the assistance of an interpreter. Please
check if you use an interpreter.
Lang1.
Lang3.
HEARING
I am able to treat patients on a doctor/patient level in A merican S ign
L anguage
Other sign language:
I have TDD equipment in the office.
GROUP
I am a full-time member of this group practice:
ADDRESS
&
(Maximum of 4 addresses or 3
addresses and 1 email address) You may list 2 other phone numbers per
address.Be certain to designate the other phone number types as follows: A=answering service/
B=beeper or pager/ C=cell or car/ E=emergency/ F=fax/ M=metro/
P=physicians only/ R=residence/ T=toll free/ V=voice mail .
Primary Office Address
City
Phone#
A
B
C
E
F
M
P
R
T
V
Other 2
A
B
C
E
F
M
P
R
T
V
Electronic Mail (e-mail) Address
Second Office Address
City
Phone#
A
B
C
E
F
M
P
R
T
V
Other 2
A
B
C
E
F
M
P
R
T
V
Third Office Address
City
Phone#
A
B
C
E
F
M
P
R
T
V
Other 2
A
B
C
E
F
M
P
R
T
V
Fourth Office Address
City
Phone#
A
B
C
E
F
M
P
R
T
V
Other 2
Type
A
B
C
E
F
M
P
R
T
V
License number** information is not published.
REQUEST FOR ADDITIONAL INFORMATION.
