Supervising / Collaborating Physician Provider information

In case you are a mid-level provider or need a supervising physician to prescribe eRx then please send us the following information of your supervising / collaborating physician as is required by SureScripts

First Name:

Middle Name:

Last Name:

NPI:

DEA:

States in which s/he is licensed along with the license number:

You can email this information to support@docvilla.com and our team will process it for you.