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MedLicense.com
Professional Medical Licensure in all 50 States
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Full Legal Name (on Identity Documents and Medical School Diploma):
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Mailing Address:
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Phone Number:
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Email:
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Date of Birth:
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Social Security Number:
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Degree Type (MD, DO, PA, NP, DDS, DMB, etc):
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Medical School Name and Location:
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Medical School Dates of Attendance & Graduation Date:
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ECFMG Number and Issue Date:
Total number of Years of PGY (Internship/Residency/Fellowships) in the USA, Canada, or Puerto Rico:
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States where you have been licensed Past and Present:
Board Certification:
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Year First Certified and Re-Certified:
What License Examination did you Take?
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Did you take more than 3 attempts on any Step of the Examination?
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Yes
No
Did you take more than 7 years to pass the Examination Sequence?
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Yes
No
Have you had any malpractice claims?
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Yes
No
Have you ever had a negative action, adverse issue, probation, arrest, or issue with a Medical School, Training Hospital, Privilege Hospital, Employer, State Medical Board, Insurance Company, Governmental Entity, Medicare, Medicaid, DEA, and etc.?
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Yes ( if yes then provide details below)
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Please provide any information about potential negative information: (i.e. Probations, Leave of Absences, Board Actions, Probations, Arrests, Disciplinary Actions, Suspensions)
What is your sex?
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Height, Weight, Eye Color, Hair Color
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Credit Card Number:
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Name on the Credit Card:
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