Physicians and physician assistants are required to enter their license number in the following format: MD12345678, so if your license number is 123, you should enter MD00000123, no extra spaces.

License Number: * Format is "MD12345678"  
First Name: *    
Last Name: *    
Zip Code: *    
Birth Date: * Format "MM/DD/YYYY"
If you are a student, click here.