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*****

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Date of Birth*

01-01-1970

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Medical School - Attended

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Name

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Year of Graduation

Residency Training

Name of program

Location

Year of Graduation

Fellowship Training

Name of program

Location

Year of Graduation

Medical License

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Ever surrendered a medical license under the threat of a disciplinary action by any Medical Board:

Yes

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Anticipated Year of Completion

Indian Medical Association

of Southern California

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Our address

Indian Medical Association of Southern California
2372 Morse Avenue # 604
Irvine
California 92614

Phone Line

(949) 316 1157

Email address

imasc(at)imasc.org

Fax

(949) 316 1158