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Physician Records
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	Physician Last Name:
	Physician First Name:
	Physician Middle Name:
	License Number:	(e.g. 012345 - 6 Characters Including Leading Zeroes)
	License Type:

	Effective Date:	From: (i.e. mm/dd/yyyy) To: (i.e. mm/dd/yyyy)

	Date Updated:	From: (i.e. mm/dd/yyyy) To: (i.e. mm/dd/yyyy)
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Department of Health