Proview errors copy

License Number

License Type

Professional License

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) RegistrationDo you have a CDS Registration Certificate?

Yes

No

Please review the missing information highlighted below.Please enter Professional License details for Practice State - VAPlease 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

License State

Do you currently 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) RegistrationDo you have a CDS Registration Certificate?

Yes

No

Please review the missing information highlighted below.Please enter Professional License details for Practice State - VAPlease 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

License State

Do you currently 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) RegistrationDo you have a CDS Registration Certificate?

Yes

No

Please review the missing information highlighted below.Please enter Professional License details for Practice State - VAPlease 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"

License State

Do you currently 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) RegistrationDo you have a CDS Registration Certificate?

Yes

No

Please review the missing information highlighted below.Please enter Professional License details for Practice State - VAPlease 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