Quantity:
CD-ROM
E-mail/
Address:
Total Price:
x Price Per Unit: $100.00 =
Format: (choose one)
The Arizona Medical Board and the Arizona Regulatory Board of Physician Assistants produces a CD-ROM containing the
Physician and Physician Assistant database on a monthly basis. The data is provided as an EXCEL file. This data disk contains
public information on Physicians and Physician Assistants including the following:
Name, License Number, Office/Mailing Address, Office Telephone Number, License Status, In-State or Out-of-State Practice,
License Issuance Date, Last Renewal Date, License Expiration Date, Education, Year of Graduation, Fields of Practice, and
Board Actions. The data disk also indicates whether a Physician holds a dispensing Certificate.
Upon receipt of payment, the data disk will be e-mailed to the addr
ess listed above or mailed to the mailing address listed below.
For your convenience, in addition to direct payments by check or money order, the Board accepts Visa, MasterCard and American
Express.
The Arizona Medical Board will only accept credit card payment via mail (US, FedEx, UPS, or any other mail carrier). Any
credit card information received via any other method will not be processed and will be destroyed.
*Data disks may also be purchased and picked up at the Board's office from 8am to 5pm. (Please call ahead for expedited service.)
Arizona Medical Board
Arizona Regulatory Board of Physician Assistants
1740 W. Adams St, Suite 4000 Phoenix, AZ 85007 Phone
(480) 551-2700 www.azmd.gov
DATA DISK REQUEST FORM
Date:
Cardholder Signature:
(If different from billing address)
Zip:State:City:Mailing Address of Cardholder:
Office Phone:
(Required)
Zip:State:City:Billing Address of Cardholder:
Name as Shown on Payment Card:
(No dashes between numbers)
Expiration Date:
Card Number:
AmexMastercardVisa
Type of Card:
(Required)
For receipt, please include an e-mail address for submission:
E-mail:
