Interstate Telehealth Registration - Personal Information

License Information

Please select the license type you are applying.

D.O.

P.A.

Biographical Information


First Name	Middle Name	Last Name	Suffix
Other Name	Maiden Name	Social Security Number	Date of Birth
Gender	Race	US Citizen	NPI Number

Create a Password

Please create a password that you will use going forward to log in to all online forms including: updating your personal/employment information, printing your license, future renewal forms, etc.

Passwords must be at least eight characters in length, including at least one capital letter, one number, and one special character (symbol) of ! @ # $ % ^ & * ( ) = - [ ] ' ; , . / { } | : < > ?


Password	Confirm your Password