DiaspoCare Healthcare Professionals Registration

Personal Data

Primary or Pending Practice Location

Fellowship/Post-Graduate/Professional Training

Professional and Academic/Faculty Affiliations

Specialty/Subspecialty Certification

Primary Specialty

Secondary Specialty

Additional Specialty:

If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.


Licensure - List all past, current and pending professional licenses.