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M.D. and D.O. Application

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M.D. and D.O. Application

ATL Black Doctor Directory Application - M.D. and D.O.

Name(Required)

First Name Last Name

What is your age?(Required)

Degree(Required)

Where did you go to medical school?(Required)

Where did you go to medical school?

Alabama

Arizona

Arkansas

California

Colorado

Connecticut

District of Columbia

Florida

Georgia

Hawaii

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

How do you want your name(including credentials) to appear in the directory?(Required)

Did you graduate from an HBCU?(Required)

What HBCU did you attend?(Required)

Alabama(Required)

Arkansas(Required)

Delaware(Required)

District of Columbia(Required)

Florida(Required)

Georgia(Required)

Kentucky(Required)

Louisiana(Required)

Maryland(Required)

Michigan(Required)

Mississippi(Required)

Missouri(Required)

North Carolina(Required)

Ohio(Required)

Oklahoma(Required)

Pennsylvania(Required)

South Carolina(Required)

Tennessee(Required)

Texas(Required)

US Virgin Islands(Required)

Virginia(Required)

West Virginia(Required)

If you did not attend an HBCU, where did you go to college?(Required)

What is your specialty? (Select all that apply)

Adolescent Medicine

Allergy and immunology

Anesthesia

Breast Surgery

Cardiology

Cardiothoracic Surgery

Colorectal Surgery

Critical Care

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

General Surgery

Geriatrics

GYN Oncology

Gastroenterology

Hematology/Oncology

Infectious Disease

Internal Medicine

Interventional radiology

Nuclear Medicine

Nephrology

Neurology

Neurosurgery

Obstetrics and Gynecology

Occupational Medicine

Ophthalmology

Orthopedic surgery

Otorhinolaryngology

Pain Management

Pathology

Pediatrics

Physical Medicine and Rehabilitation

Plastic Surgery

Preventive Medicine

Psychiatry

Pulmonology

Radiation Oncology

Radiology

Rheumatology

Sports Medicine

Surgical Oncology

Surgery

Trauma and Acute Care Surgery

Urology

Vascular Surgery

What is your sub-specialty? (Select all that apply)(Required)

Where did you do your residency?(Required)

Did you do a fellowship?(Required)

Yes

No

In what subspeciality did you do your fellowship?(Required)

Are you Board Certified?(Required)

Yes

No

Do you have a current license to practice medicine in the state of Georgia?(Required)

Yes

No

Are you currently clinically active and seeing patients?

If you are taking appointments, please provide the link to your appointment and scheduling platform.(Required)

Type of practice or healthcare system you are employed by. Check all that apply.

Medical School Faculty

Healthcare System

Private/Group Practice

Corporate/Industry

Retired

Healthcare System(Required)

Private/Group Practice(Required)

Please mention other Practice(Required)

Corporate/Industry(Required)

Company Name

Government(Required)

Agency or Organization Name

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Select all cities where you have a practice location.

Atlanta

Acworth

Alpharetta

Austell

Avondale Estates

Buford

Canton

Carrollton

Chamblee

Clarkston

College Park

Conyers

Covington

Cumming

Dacula

Dallas

Decatur

Doraville

Douglasville

Duluth

Dunwoody

East Point

Fairburn

Fayetteville

Forest Park

Griffin

Hampton

Hiram

Jonesboro

Kennesaw

Lawrenceville

Lilburn

Lithia Springs

Lithonia

Locust Grove

Loganville

Lovejoy

Mableton

Marietta

Mcdonough

Morrow

Newnan

Norcross

Peachtree City

Powder Springs

Riverdale

Roswell

Sandy Springs

Senoia

Sharpsburg

Smyrna

Snellville

Stockbridge

Stone Mountain

Sugar Hill

Suwanee

Tucker

Tyrone

Union City

Villa Rica

Vinings

Winder

Woodstock

Facebook

ie. https://www.facebook.com/myabb

Instagram

ie. https://www.instagram.com/myabb

Facebook

ie. https://www.facebook.com/myabb

Facebook

ie. https://www.facebook.com/myabb

Website

ie. https://www.mybdd.com

Other

ie. https://...

LGBTQIA+ Friendly Practice

How many years have you been practicing?(Required)

Memberships

Sororities(Required)

Fraternities(Required)

Are you a member of any of the following organizations?(Required)

Atlanta Medical Association

Georgia State Medical Association

National Medical Association

Student National Medical Association

Mocha Docs

None of the above

Other

Other(Required)

Are you a member of any other nationally based social organizations? (Select All That Apply)(Required)

Jack and Jill of America

The Links, Incorporated

100 Black Men Of America, Inc.

100 Black Women of America, Inc.

N/A

Other

Other(Required)

Are you a member of any specialty based professional organizations, eg. American College of Surgeons

GETTING TO KNOW YOU

Do you have any other professional degrees?(Required)

N/A

MBA

MPH

MHA

MPA

PHD

JD

Other

Do you have any unique talents, experiences, or accomplishments?

Have you won any professional, humanitarian, or other significant awards?

Do you have any academic appointments?

Do you serve on any boards, or have any professional or community based leadership roles?

Do you have a sliding scale for fees?

Do you offer video visits?

What is your philosophy for patient care?

Do you have an introduction video you would like to display? Enter the URL here.

YouTube, Vimeo Link etc.

Image #1: Professional Headshot / Profile Picture(Required)

Max. file size: 2 MB.

Profile Image #2: Profession Image(Required)

Max. file size: 2 MB.

Ideas: In your office, outside your facility, with your staff....

Profile Image #3: Leisure/Family(Required)

Max. file size: 2 MB.

Profile Image #4: Leisure/Family(Required)

Max. file size: 2 MB.

Profile Image #5: Community Engagement Image(Required)

Max. file size: 2 MB.

Ideas: Leadership, Volunteer, Organizations

Upload Your CV(Required)

Max. file size: 2 MB.

Ideas: Leadership, Volunteer, Organizations

Personal quote, statement, or motto

Personal info

Please type in your NPI number

(Required)

I acknowledge that the publishers of the directory will use my NPI number to do a basic screening to ensure that the credentials and my profile that I provided are accurate.

Have you ever had your medical license revoked or suspended (This information will not be displayed in the directory.)(Required)

Yes

No

Please explain the details of the revocation or suspension(Required)

Have you ever been convicted of a felony? (This information will not be displayed in the directory.)(Required)

Yes

No

Personal/Preferred Gender Pronouns (PGP)(Required)

Have you ever been convicted of a felony? (This information will not be displayed in the directory.)(Required)

He/Him/His

She/Her/Hers

They/Them/Theirs

Other PGP

Cell Phone Number(Required)

WILL NOT BE MADE PUBLIC

Personal Email(Required)

WILL NOT BE MADE PUBLIC

Bio(Required)

Opportunities

Are you willing to be a presenter in a series of brief medical educational videos that we are creating(Required)

Yes

No

Are you willing to have your image and story featured on digital flash cards of Black Health professionals that we are creating(Required)

Yes

No

Are you willing to mentor underrepresented Individuals from the following groups? (Check all that apply)

Pre-Med students

Current medical students

Medical residents

Physicians early in their career

Not at this time

Are you willing to be listed on our speaker's panel of subject matter experts? If so, what is your specific area of expertise?(Required)

Atlanta, GA

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fkjsurge@MyBDD.com

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Adolescent Medicine
Child Abuse Pediatrics
Developmental-Behavioral Pediatrics
Hospice and Palliative Medicine
Medical Toxicology
Neonatal-Perinatal Medicine
Cardiology
Critical Care Medicine
Emergency Medicine
Endocrinology
Gastroenterology
Hematology-Oncology
Infectious Diseases
Nephrology
Pulmonology
Rheumatology
Surgery
Transplant Hepatology
Sleep Medicine
Sports Medicine