| DOCUMENT |
DETAIL |
| National Board of Medical Examiners |
Certificate 84740, issued 1965 |
| New York State Medical License |
Number 096798, issued 1966 (inactive) |
| Virginia State Medical License |
Number 20416, issued 1969 (inactive) |
| New Jersey State Medical License |
Number MA026333, issued 1972 (inactive) |
| American Board of Psychiatry and Neurology (Psychiatry) |
Certificate 12001, issued 1972 |
| Medicaid |
UPIN C59768 (inactive) |
| Medicaid Provider |
Service Number 0827207 (inactive) |
| Medicare |
Number PU460906 (inactive) |
| DEA Registration |
Number AP5469211 for schedules 2, 2N, 3, 3N, 4, 5 (inactive) |
| NJ CDS Registration |
Number D014073, for schedules 2, 3, 4, 5 (inactive) |