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The information submitted here is for TMV use only.

Specialties with board certification
Board certification *      Year
Licensed in: State(s)
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License Number(s)
Medical school?
Where did you do your residency?
Languages spoken and fluency
Military experience *
Local (states) and federal DEA
information / numbers *
Has your license or DEA in any State ever revoked or temporarily suspended?  Yes No
Contact address
Preferred email
Preferred phone
Hospital privileges  Yes No