LOUISIANA STATE BOARD OF MEDICAL EXAMINERS



LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

630 Camp Street, New Orleans, LA 70130

PHONE (504) 568-7515 FAX (504) 568-3176

Web site: lsbme.

(Revised: 1/4/2018)

REPORT REQUEST FORM

** Complete this form PRIOR to printing**

**Please return this form with check/money order in the amount of $200 to the above address, ATTN: Tracy K. Mauro

Contact me if you have any questions at tmauro@lsbme. or (504) 568-7515.

Please DOUBLE CHECK your selections. ANY CHANGES to these specifications will be considered a new request and regular fees will be incurred.

CATEGORIES: Active Licenses Only (or) Active & Inactive Licenses

| ALL MD/DO & Allied Health |(AND/OR) | ALL Clinical Laboratory Personnel |

|(OR) choose specific ones below | |(OR) choose specific ones below |

| | | |

|Acupuncture Detoxification Specialist Occupational Therapy Assistant | |CLS-Generalist |

|Athletic Trainer Osteopathy | |CLS-Specialist |

|Clinical Exercise Physiologist Perfusionist | |CLS-Technician |

|Dispensing Registration Physician | |Cytotechnologist |

|Graduate Educational Temp Permit Physician Acupuncturist | |Laboratory Assistant |

|Internship Registration Physician Assistant | |Phlebotomist |

|Licensed Acupuncturist Podiatrist | | |

|Licensed Respiratory Therapist Polysomnography | | |

|Medical Psychologist Private Radiological Technology | | |

|Medical Psychologist Advanced Practice Supervising Physicians | | |

|Midwife Telemedicine | | |

|Occupational Therapist Therapeutic Marijuana Registration | | |

MEDIA TYPE: EMAIL CD-ROM

DATA FORMAT: Excel Delimited ASCII TEXT

SORT BY:      

CHECK THE FIELDS THAT ARE NEEDED:

| ALL | Expiration Date | Specialties (MD’s ONLY) |

| Name | Credential Status | Medical School Information |

| Credential # | Discipline Status |**The ONLY address that is provided by the LSBME |

| | |is the licensees BUSINESS address** |

| Credential Type (License or Permit) | Primary Business Address | |

| Credential Definition (Category of Licensure) | Primary Business Parish | |

| First Issuance Date | Primary Business Phone | |

BUSINESS ADDRESS: Both In-State & Out of State In-State Only

SPECIALTIES[1]: (MD’s ONLY): ALL (or) List (Choose Specialties on page 3 and include it with request.)

PARISH: ALL (or) List (Choose Parishes on page 4 and include it with request.)

COMMENTS:      

PLEASE FILL OUT YOUR INFORMATION BELOW: **COMPLETE THIS FORM PRIOR TO PRINTING**

Name:       Company:      

Street Address:       City/State/Zip:      

Phone Number:       E-Mail Address:      

Amount Enclosed: $      (CHECK OR MONEY ORDER ONLY) Date:      

LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

630 Camp Street, New Orleans, LA 70130

Web site: lsbme.

The price for a Report Request is $200.00

Payable by Check Or Money Order Only!

Make checks/money order payable to :

Louisiana State Board of Medical Examiners or LSBME

Mail or Fed-Ex payment along with your request form to:

Louisiana State Board of Medical Examiners

Attention: Tracy K. Mauro

630 Camp Street

New Orleans, LA 70130

The fee must be paid before your request can be processed.

Reports process time is approximately 2 weeks upon receipt of payment.

If after 2 weeks a report is not received, contact Tracy K. Mauro, IT Technical Support Specialist at 504-568-7515 or tmauro@lsbme.

LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

630 Camp Street, New Orleans, LA 70130

Web site: lsbme.

Specialties

Adolescent Medicine

Aerospace Medicine

Allergy

Allergy and Immunology

Anesthesiology

Broncho-Esophagology

Blood Banking

Cardiovascular Diseases

Critical Care Medicine

Dermatology

Dermatopathology

Diabetics

Emergency Medicine

Endocrinology

Endocrinology, Reproductive

Family Practice

Gastroenterology

General Practice

General Preventive Medicine

Geriatrics

Gynecological Oncology

Gynecology

Hematology

Hypnosis

Immunology

Immunology, Diagnostic Lab

Immunopathology

Infectious Diseases

Internal Medicine

Laryngology

Legal Medicine

Maternal and Fetal Medicine

Maxillofacial Surgery

Medical Microbiology

Neonatal-Perinatal Medicine

Neoplastic Diseases

Nephrology

Neurology

Neurology, Child

Neuropathology

Nuclear Medicine

Nuclear Radiology

Nutrition

Obstetrics

Obstetrics-Gynecology

Occupational Medicine

Oncology

Oncology, Radiation

Ophthalmology

Otology

Otolaryngology

Pathology

Pathology, Anatomic

Pathology, Chemical

Pathology, Clinical

Pathology, Forensic

Pediatrics

Pediatrics, Allergy

Pediatrics, Cardiology

Pediatrics, Endocrinology

Pediatrics, Hematology-Oncology

Pediatrics, Nephrology

Pediatrics, Pulmonology

Pharmacology

Physical Medicine and Rehabilitation

Psychiatry

Psychiatry, Child

Psychoanalysis

Psychosomatic Medicine

Public Health

Pulmonary Diseases

Radiology

Radioisotopic Pathology

Radiology, Diagnostic

Radiology, Pediatric

Radiology, Therapeutic

Rheumatology

Rhinology

Surgery, Abdominal

Surgery, Cardiovascular

Surgery, Colon and Rectal

Surgery, Facial Plastic, Oto.

Surgery, General

Surgery, Hand

Surgery, Head and Neck

Surgery, Neurological

Surgery, Orthopedic

Surgery, Pediatric

Surgery, Plastic

Surgery, Thoracic

Surgery, Traumatic

Surgery, Urological

Surgery, Vascular

Urology

LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

630 Camp Street, New Orleans, LA 70130

Web site: lsbme.

[pic]

Louisiana Parishes

|Parish Names |

| |Acadia | |Morehouse |

| |Allen | |Natchitoches |

| |Ascension | |Orleans |

| |Assumption | |Ouachita |

| |Avoyelles | |Plaquemine |

| |Beauregard | |Pointe Coupee |

| |Bienville | |Rapides |

| |Bossier | |Red River |

| |Caddo | |Richland |

| |Calcasieu | |Sabine |

| |Caldwell | |St. Bernard |

| |Cameron | |St. Charles |

| |Catahoula | |St. Helena |

| |Claiborne | |St. James |

| |Concordia | |St. John the Baptist |

| |DeSoto | |St. Landry |

| |East Baton Rouge | |St. Martin |

| |East Carroll | |St. Mary |

| |East Feliciana | |St. Tammany |

| |Evangeline | |Tangipahoa |

| |Franklin | |Tensas |

| |Grant | |Terrebonne |

| |Iberia | |Union |

| |Iberville | |Vermilion |

| |Jackson | |Vernon |

| |Jefferson | |Washington |

| |Jefferson Davis | |Webster |

| |Lafayette | |West Baton Rouge |

| |Lafourche | |West Carroll |

| |LaSalle | |West Feliciana |

| |Lincoln | |Winn |

| |Livingston | | |

| |Madison | | |

[pic][pic]

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[1] Disclaimer: The physician’s specialty certification information in the LSBME database is updated periodically with data provided by the physician. As it is not a requirement for licensure, it is not primary source verified. Due to the possibility of reporting and processing errors, the accuracy and completeness of records cannot be guaranteed. The LSBME cannot be held responsible for incomplete or inaccurate information in each physician’s record. Visitors assume sole responsibility for any decisions made based upon this information. If you require authentication of the specialty certification information, contact the respective specialty board directly.

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For LSBME office use only

____ Request Complete ______________

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