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]
-----------------------
[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.
-----------------------
For LSBME office use only
____ Request Complete ______________
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