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The document contains a form requesting information about a practitioner's professional licenses, certifications, and practice status. It notes several required fields need to be completed, including details about a license for the state of Virginia and expiration dates.
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- 1. License Number License Type ProfessionalLicense License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certificate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certificate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the field labeled, "License Number" Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certificate Yes No License State ADD 6829475 State* Do you currently practice in this in this state? Yes No
- 2. License State Do youcurrently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certificate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certificate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the field labeled, "License Number" Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certificate Yes No ADD
- 3. License State Do youcurrently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certificate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certificate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the field labeled, "License Number" Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certificate Yes No ADD Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "License Number" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "State"
- 4. License State Do youcurrently practice in this in this state? License Number License Type Yes No Professional License License Status Issue Date Expiration Date Are you a participating Medicare provider? Medicare Yes No Medicare Number State Are you a participating Medicaid provider? Medicaid Yes No Medicaid Number State * * * Do you have a DEA Registration Certificate? DEA Registration Controlled Dangerous Substance (CDS) Registration Do you have a CDS Registration Certificate? Yes No Please review the missing information highlighted below. Please enter Professional License details for Practice State - VA Please enter the field labeled, "License Number" Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Do you have a Educational Commission for Foreign Medical Graduates (ECFMG) Number? Yes No ECFMG Issue Date ECFMG Number Workers Compensation Number USMLE Exam Date USMLE Number Workers Compensation Number ECFMG DEA Number State Issue Date Expiration Date Click Add to enter another DEA Registration Certificate Yes No ADD Please enter the field labeled, "License State" Please enter the field labeled, "Do you currently practice in this state?" Please enter the field labeled, "License Number" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "Expiration Date" Please enter the field labeled, "State" Please enter the field labeled, "State" Select Date Select Date Please Select Please Select