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M. Military Medical Training:

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current_former2

Military Branch Name:

Military Branch Other:

Director's Name for Medical Traning:

Name of Mlitary Medical Facility:

Military Facility Addreass:

Military Facility City:

Military Facility State:

Military Facility Country:

Military Facility Zip Code:

Medical Staff Office Phone Number:

Medical Staff Office Fax Number:

Type of Discharge:

Discharge Text:

State of Milatery License:

Stae Milatery License Number:

State License Issue Date:

State License Expiration Date:

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⇒

tim2

Army

Coast Guard

Captain

John Smith MD.

234234 9th Ave.

asdf

Va

USA

20103

235.258.8956

235.258.9999

Va

07/11/2006

08/19/2011

Yes

234234 9th Ave.

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record_id	1
Master_ID	tim2
current_former2
Military Branch Name:
Military Branch Other:
Military Rank:
Director's Name for Medical Traning:
Name of Mlitary Medical Facility:
Military Facility Addreass:
Military Facility City:
Military Facility State:
Military Facility Country:
Military Facility Zip Code:
Medical Staff Office Phone Number:
Medical Staff Office Fax Number:
Date From:
Date To:
Type of Discharge:
Discharge Text:
State of Milatery License:
Stae Milatery License Number:
State License Issue Date:	/ /
State License Expiration Date:	/ /
Did you have Civilian Patients?