Step 1
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Email Address
Home Address
State
Zip Code
Primary Address same as
Primary Address
City
State
Zip Code
Billing Address same as
Billing Address
City
State
Zip Code
Valid State Issued ID
Phone no
Step 2
NPI Number
Taxonomy
License
DEA / Drug License
Controlled Substance Registration
Step 3
Malpractice Company Detail
Step 4
California resident?
Acknowledgment
Authorization
Applicant Name
Legal Guardian Name (if applicant is under 18)
Applicant/Legal Guardian Email
Signature