Contents


Practitioner Information

Name
  • All name changes must be reported to the New Jersey State Board of Medical Examiners at P.O. Box 183 Trenton NJ 08625 or New Jersey State Board of Optometrists at P.O. Box 45012, Newark, NJ 07101.


    Mailing Address (required)

  • Medical Doctors/Podiatrists: This address is for Profile contact purposes only and will not be made available to the public. 
      Contact the New Jersey State Board of Medical Examiners to update your mailing address for licensure purposes at 609-826-7100

  • Optometrists: This address is for Profile contact purposes only and will not be made available to the public as part of the Profile. 
      Contact the New Jersey State Board of Optometrists to update your mailing address for licensure purposes at PO Box 45012, Newark, NJ 07101.

  • Review the preprinted data.
  • If data is incorrect, enter the correct information. Make any necessary changes. (Not all information can be changed.)
  • If you are reporting an address that is located within the United States, please do not enter any information into Line 4 as this will be used to store the City, State and Zip Code information. Enter the City, State and Zip Code in the individual fields provided.
  • If you are reporting an address that is not located within the United States, please enter the complete address information in Lines 1 through 4. Do not enter any information in the City, State or Zip Code fields.



    Additional Contact Information (Optional)


    This information is for contact purposes only and will not be made available to the public. Enter the following information (any format will be accepted):
  • Daytime Phone Number: The daytime phone number at which you can be reached in the event that a question arises regarding information that you have submitted in your profile.
  • Fax Number
  • E-Mail address


    License to Practice (Required)


    Verify the preprinted information. The license number and year conferred information cannot be changed. 
  • If this information is in error or blank, 
  • Medical Doctors and Podiatrists should contact the New Jersey State Board of Medical Examiners at PO Box 183 Trenton NJ 08625, and 
  • Optometrists should contact the New Jersey State Board of Optometrists at PO Box 45012, Newark, NJ 07101.
  • If initially licensed to practice medicine outside of the state of New Jersey, enter the year you were first licensed.


    Primary Specialty (Required)

  • Review the pre-printed data.
  • Medical Doctors and Podiatrists Only - If you would like to change the specialty that is pre-printed or if a specialty is not pre-printed; 
  • Click on the drop down box to select a specialty.  
  • You can add up to 4 additional specialties to your profile, using the drop down selection.



    When finished, click one of the buttons at the bottom of the screen:
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