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Existing LIDS members: Please read this announcement prior to completing this page.

To qualify for for membership in the Long Island Dermatological Society you must be a physician who devotes his or her practice to dermatology, and who practices or resides on Long Island.

To submit an application for membership, please fill out the form below.

Fields in red are required. Non-required fields which are completed will be displayed on your profile.

In order to conform with postal guidelines we request that you enter any suite number (abbreviated Ste) on the same line as your street address.

You may opt not to display some of the required fields in your profile. Simply select the checkbox to the right of the fields where this option is available to hide the information from your profile.

Applications must be accompanied by 2 letters of reference from active society members. Letters should be addressed to:

The Long Island Dermatological Society
c/o Shannon Hughes
181 N. Belle Mead Road, Suite # 6
East Setauket, NY 11733-9221

Once received, applications will be voted upon by the membership at the next scheduled meeting. An annual fee of $200.00 will be required to activate membership.

Information received is subject to validation by the Long Island Dermatological Society. The Long Island Dermatological Society reserves the right to remove false, misleading or inappropriate information and edit copy to conform to the standard profile format.

 
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PERSONAL INFORMATION
First Name
Middle Initial
Last Name
Title(s) (Separate multiple with comma ",")
Gender Female     Male  hide
Date of Birth
     
 hide

Email  hide
Confirm Email

Password  hide
Confirm Password
 
PRIMARY PRACTICE
Primary Practice Name
Street Address 1
City 1
State 1
Zip Code 1 (5 digits)
Telephone 1 (area code first) -
Fax 1 (area code first) -
Website 1
Office Hours 1
  From     To
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
Sunday 
 
SECONDARY PRACTICE
Secondary Practice Name
Street Address 2
City 2
State 2
Zip Code 2 (5 digits)
Telephone 2 (area code first) -
Fax 2 (area code first) -
Email 2  hide
Confirm Email 2
Website 2
Office Hours 2
  From     To
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
Sunday 
 
LICENSURE  hide
Medical License No.
State
Date of Original Licensure
     
Current Expiration
     
 
BOARD CERTIFICATION
Board Eligibility Board Certified      Board Eligible
Board Certification 1  hide
       hide
Board Certification 2  hide
       hide
Board Certification 3  hide
       hide
 
HOSPITAL AFFILIATIONS  hide
Institution 1
Institution 2
Institution 3
Institution 4
 
MEDICAL SCHOOL
Medical School  hide
Year of Graduation  hide
 
RESIDENCY TRAINING  hide
Residency 1
Residency 2
Residency 3
 
FELLOWSHIP TRAINING  hide
Fellowship 1
Fellowship 2
Fellowship 3
 
ACADEMIC APPOINTMENTS  hide
Institution 1  Position 
Institution 2  Position 
Institution 3  Position 
 
MEMBERSHIP IN PROFESSIONAL SOCIETIES  hide
Membership 1
Membership 2
Membership 3
Membership 4
Membership 5
Membership 6

AAD Member Number  hide
 
PROFESSIONAL BIOGRAPHY (limit to 1000 words)
 
KEY PROFESSIONAL ACHIEVEMENTS AND AWARDS
Achievement 1
Achievement 2
Achievement 3
Achievement 4
Achievement 5
Achievement 6
Achievement 7
Achievement 8
Achievement 9
Achievement 10
 
INSURANCE
Health Care Insurance Participation
(enter one per line)
Medicare/Medicaid Participation Accept Medicare     Accept Medicaid
 
AREAS OF SPECIALIZATION
Academic DermatologyLaser Therapy of Vascular Lesions and Birthmarks
Acne and RosaceaLiposuction
Botox TherapyMicrodermabrasion and/or Chemical Peels
Collagen and/or other Skin FillersMohs Micrographic Surgery
Cosmetic DermatologyNail Disorders
Cutaneous T-Cell LymphomaPediatric Dermatology
Dermatologic SurgeryPemphigus and Blistering Disorders
DermatopathologyPhototherapy (light therapy)
Eczema, Atopic and Contact DermatitisPigmentary Disorders
General DermatologyPsoriasis
Geriatric DermatologyRheumatologic Diseases
Hair DisordersSexually Transmitted Diseases
Hair TransplantationSkin Cancer Diagnosis and Therapy
Laser Hair RemovalSpider and Varicose Veins
Laser Resurfacing and/or RejuvinationUlcers and Wound Healing
 
LANGUAGES other than English
ArabicKorean
ArmenianPolish
ChinesePortuguese
FrenchRomanian
GermanRussian
GreekSign Language
HebrewSpanish
HungarianThai
ItalianYiddish
Japanese  
 
   
 
 
 
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