Database request form

* indicates a required field

Your first name: *

Your last name: *

Your email address: *

Confirm your email address: *

Business name:

Street address: *

Additional address:

City: *

State: *

Zip code: *

Telephone number: *

Fax number:

Which license statuses?: *
Active status only
All statuses

Which license types?: *

MD - Medical Doctor
DO - Doctor of Osteopathy
L - Limited MD and Limited DO
PA - Physician Assistant
AA - Anesthesiologist Assistant
TA - Temporary Assistant (received before passing test)
SP - Special Purpose
RSV - Retired Senior Volunteer Program
ACSC - Alabama Controlled Substances Certificate

Additional fields: ($0.01 per record will be added for each additional field selected) *

No additional fields (just the base fields)

Or select from the following list:

Phone (provided by licensee and not verified)
Fax (provided by licensee and not verified)
County
Gender
Date of death
Expiration date
Original license date
Original license source (only valid for MD, DO and Limited licenses)
Medical school attended
Dates attended medical school
Status of the license (included only if you are asking for all statuses)
Primary specialty (provided by licensee, not verified)
Is board certified in primary specialty (provided by licensee, not verified)
Secondary specialty (provided by licensee, not verified)
Is board certified in secondary specialty (provided by licensee, not verified)
Public record (will receive a "Yes" or "No", no other information is included)
Has an ACSC (will only receive "A" if the licensee has or has had an ACSC)
NCC certified (only for PA or AA licenses)
NCC number (only for PA or AA licenses)

Use the Additional Information block below to include additional instructions.

For example, if you just want the list to include physicians located in certain cities or counties, then list those cities and counties in the additional instructions. Or if you want to just include physicians with certain specialties, list each specialty in the additional instructions. If selecting specific specialties, please make sure they are on our list of specialties.

Additional Information: