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Physician Information

Constituent Type *

Medical Professional

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First Name *

Last Name *

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Secondary Language

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Medical Professional Type *

Physician

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Include my information in the IDF Physician Finder

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Seeing new patients? *

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Patient Type

Adult

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If you do not schedule appointments for patients then please provide your main contact number.

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ENT

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Hematology

Immunology

Infectious Disease

Internal Medicine

Pediatrics

Pulmonology

Rheumatology

Other

Other Specialty *

Size of Practice

Size of Practice

Patients with PI *

Yes

No

Number of PI Patients *

Number of Patients with PI is for internal use only. This will not be shared publicly.

PI's

Specific PI's Followed

Agammaglobulinemia (XLA)

Ataxia Telangiectasia

Chronic Granulomatous Disease

Common Variable Immunodeficiency

Complement Deficiency

DiGeorge Syndrome

Hemophagocytic Lymphohistiocytosis Syndrome (HLH)

Hereditary Angiodema

Hyper IgE Syndrome

Hyper IgM Syndrome

Hypogammaglobulinemia

IgG Subclass Deficiency

Selective IgA Deficiency

Severe Combined Immunodeficiency

Severe Congenital Neutropenia

Specific Antibody Deficiency

Wiskott-Aldrich Syndrome

Additional PI's Followed

Credentials

Professional Memberships

Board Certifications *

Hospital Affiliation

Degree

Additional Degrees

IVIG Administered in Office

Yes

No

Additional Notes

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Immune Deficiency Foundation
110 West Road, Suite 300
Towson, Maryland 21204
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Immune Deficiency Foundation is a 501(c)(3) organization (EIN: 52-1214782)

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