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Medical School:

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Years in Practice (Please enter as a number, i.e. 1, 2, etc…)

Year of Birth Year of Birth 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Category Category Physician Nurse Nurse Practitioner Physician’s Assistant Pharmacist Hospital Executive/Director/Manager Managed Care Executive Patient-Caregiver All others

Practice Type Practice Type Private Group Other NA

Hospital Affiliation

Primary Specialty Primary Specialty Addiction Medicine Aerospace Medicine Allergy and Immunology Anesthesiology Audiology Blood Banking/Transfusion Medicine Cardiovascular Diseases Chiropractic Medicine Critical Care Medicine Dentistry Dermatology Electrophysiology Emergency Medicine Endocrinology Gastroenterology Genetics Geriatrics Gynecology Hematology Hematology and Oncology Hemophilia Specialist Hepatology HIV Specialist Hospitalist Immunology Infectious Diseases Internal Medicine Interventional Cardiology Interventional Radiology Legal Medicine Neonatology Nephrology Neurology Neuropathology Nuclear Medicine Obstetrics and Gynecology Oncology Ophthalmology Optometry Otolaryngology Pain Management Pathology Pediatric Allergy and Immunology Pediatric Anesthesiology Pediatric Cardiovascular Diseases Pediatric Critical Care Medicine Pediatric Dentistry Pediatric Dermatology Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Genetics Pediatric Hematology Pediatric Hematology and Oncology Pediatric Immunology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Neurology Pediatric Oncology Pediatric Ophthalmology Pediatric Orthopedics Pediatric Otolaryngology Pediatric Pathology Pediatric Psychiatry Pediatric Pulmonology Pediatric Radiation Oncology Pediatric Radiology Pediatric Rehabilitation Pediatric Rheumatology Pediatric Urology Pediatrics Pediatric-Surgery Physical Medicine and Rehabilitation Podiatry Primary Care (General Practice/Family Practice/Family Medici Psychiatry Psychiatry-Geriatrics Psychology Pulmonology Radiation Oncology Radiology Reproductive Endocrinology Respiratory Therapy Rheumatology Sleep Medicine Sports Medicine Surgery-Abdominal Surgery-Bariatric Surgery-Cardiothoracic Surgery-Cardiovascular Surgery-Dermatology Surgery-Endocrinology Surgery-Gastroenterology Surgery-General Surgery-Hand Surgery-Head and Neck Surgery-Neurology Surgery-Obstetrics and Gynecology Surgery-Oncology Surgery-Ophthalmology Surgery-Oral Surgery-Orthopedics Surgery-Plastic Surgery-Podiatry Surgery-Pulmonology Surgery-Radiology Surgery-Thoracic Surgery-Transplant Surgery-Trauma Surgery-Urology Surgery-Vascular Urology Other

Primary Board Status Primary Board Status Eligible Certified

Primary Specialty Other

Secondary Specialty Secondary Specialty Addiction Medicine Aerospace Medicine Allergy and Immunology Anesthesiology Audiology Blood Banking/Transfusion Medicine Cardiovascular Diseases Chiropractic Medicine Critical Care Medicine Dentistry Dermatology Electrophysiology Emergency Medicine Endocrinology Gastroenterology Genetics Geriatrics Gynecology Hematology Hematology and Oncology Hemophilia Specialist Hepatology HIV Specialist Hospitalist Immunology Infectious Diseases Internal Medicine Interventional Cardiology Interventional Radiology Legal Medicine Neonatology Nephrology Neurology Neuropathology Nuclear Medicine Obstetrics and Gynecology Oncology Ophthalmology Optometry Otolaryngology Pain Management Pathology Pediatric Allergy and Immunology Pediatric Anesthesiology Pediatric Cardiovascular Diseases Pediatric Critical Care Medicine Pediatric Dentistry Pediatric Dermatology Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Genetics Pediatric Hematology Pediatric Hematology and Oncology Pediatric Immunology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Neurology Pediatric Oncology Pediatric Ophthalmology Pediatric Orthopedics Pediatric Otolaryngology Pediatric Pathology Pediatric Psychiatry Pediatric Pulmonology Pediatric Radiation Oncology Pediatric Radiology Pediatric Rehabilitation Pediatric Rheumatology Pediatric Urology Pediatrics Pediatric-Surgery Physical Medicine and Rehabilitation Podiatry Primary Care (General Practice/Family Practice/Family Medici Psychiatry Psychiatry-Geriatrics Psychology Pulmonology Radiation Oncology Radiology Reproductive Endocrinology Respiratory Therapy Rheumatology Sleep Medicine Sports Medicine Surgery-Abdominal Surgery-Bariatric Surgery-Cardiothoracic Surgery-Cardiovascular Surgery-Dermatology Surgery-Endocrinology Surgery-Gastroenterology Surgery-General Surgery-Hand Surgery-Head and Neck Surgery-Neurology Surgery-Obstetrics and Gynecology Surgery-Oncology Surgery-Ophthalmology Surgery-Oral Surgery-Orthopedics Surgery-Plastic Surgery-Podiatry Surgery-Pulmonology Surgery-Radiology Surgery-Thoracic Surgery-Transplant Surgery-Trauma Surgery-Urology Surgery-Vascular Urology Other

Secondary Board Status Secondary Board Status Eligible Certified

Secondary Specialty Other

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