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(800) 400 MDLIVE
First Name
Last Name
Email
Phone Number
NPI
Type of Provider
Are you a MD or DO
MD
DO
Are you Board Certified in any of the following? (Use "command/ctrl + click" to select mutiple)
American Board of Internal Medicine
American Board of Family Medicine
American Board of Emergency Medicine
American Board of Pediatrics
American Board of Psychiatry
Which states are you licensed in? (Use "command/ctrl + click" to select mutiple)
When did you complete you residency?
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Do you currently hold an active, current DEA Registration?
Yes
No
Are you willing to commit to a minimum of 8-10 hours per week?
Yes
No
Are you able to offer consults in languages other than English? If so, please select the languages. (Use "command/ctrl + click" to select mutiple)
Are you currently involved in any open or pending professional liability actions, criminal, or civil cases?
Yes
No
Are you currently a Medicaid Provider?
Yes
No
Do you currently have an active, closed, open, or pending investigation or sanction from any regulatory agency (i.e. state board)?
Yes
No
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