Name: DANIEL ALAN SMALL. Online Submission Date = Renewal Question Zire you submiting a name change wih this renewal? ‘Are you licensed in another licensing jurisdiction in this profession (any status)? Since your last renewal, has a licensing jurisdiction taken any disciplinary action against you? Since your last renewal, have you been convicted af a crime? Since your last renewal, have you withdrawn an application for icensure in another licensing juristiction? Have you met your current CE requirements? Since your last renewal, have your provider privileges been terminated by any medical assistance ‘agency for cause? Since your last renewal, have you had practice prvleges denied, revoked or restricted in a hospital or health care facity? Since your last renewal, have you had your DEA registration denied, revoked or restricted? Since your last renewal, have you been arrested for criminal homicide, aggravated assault, sexval offenses or drug offenses in any state, tertory or country? Do you maintain current medical professional liability insurance in the Commonweelth? Medical Renewal - Since your last renewal, have you been the subject of a civil malpractice law sult? ‘Are you submitting a name change with this renewal? ‘Are you licensed in another licensing jurisdiction in this profession (any status)? ‘Since your last renewal, has @ licensing jurisdiction taken any disciplinary action against you? ‘Since your last renewal, have you been convicted of a crime? Since your last renewal, have you withdrawn an application for licensure in another licensing justiction? Have you met your current CE requirements? Since your last renewal, have your provider privileges been terminated by any medical assistance ‘agency for cause? ‘Since your last renewal, have you had practice privileges denied, revoked or restricted in a hospital or health care facility? ‘Since your last renewal, have you had your DEA registration denied, revoked or restricted? ‘Since your last renewal, have you been arrested for criminal homicide, aggravated assault, sexual offenses or drug offenses in any state, territory or country? Do you maintain current medical professional labilty insurance in the Commonwealth? Medical Renewal - Since your last renewal, have you been the subject of a civil malpractice law suit? ‘Are you submitting a name change with this renewal? ‘Are you licensed in another licensing jurisdiction in this profession (any status)? ‘Since your last renewal, has a licensing jurisdiction taken any disciplinary action against you? ‘Since your last renewal, have you been convicted of a crime? ‘Since your last renewal, have you withdrawn an application for licensure in another licensing juristiction? Have you met your current CE requirements? ‘Since your last renewal, have your provider privileges been terminated by any medical assistance agency for cause? Since your last renewal, have you had practice privileges denied, revoked or restricted in @ hospital or health care facility? ‘Since your last renewal, have you had your DEA registration denied, revoked or restricted? ‘Since your last renewal, have you been arrested for criminal homicide, aggravated assault, sexual offenses or drug offenses in any state, territory or country? Do you maintain current medical professional liabilty Insurance in the Commonwealth? ‘Medical Renewal - Since your last renewal, have you bean the subject of a civil malpractice law sult? ‘Are you submiting a name change with this renewal? ‘Ae you licensed in another licensing jurisdiction inthis profession (eny status)? Since your last renewal, has a licensing jurisdiction taken any disciplinary action against you? Since your last renewel, have you been convicted of a crime? i i zz cw MOWRCTIVR ATU PACK AE MH™ Om MHL BRAN OUR BOHR, Mm Th MAOULEND, TOD DRE APHLA RAGUERKD TH AnD a QUNATTE, ER DATE A ‘He Memawnirio ano eronneD WON ecu A TOUR Ase aE ro TF TONY 0 1 eR, IRENE YO Tw Haneda a A PLONE UM- HARiERERS Bae mossngtg: pie itn to crickets. ato Sindtatt gnyvotn won Gn inn 91) sant spe ‘cain 9 tos, cnmure Toston auto wero tical sp. sar ten Rie eee MeO re rt A et me ‘ecetent rm o#.98 its cousin Fou A Bie RSLS ees Commo farsi onan in To REAL rm AFD x Mori sar, “BRON ‘tices sees» apigniriog ee etoricso, | _ SY ae sh ys inn HeacTct mein sm, ion, einrmmtD, Hasire, | ‘of bustinainh Se thevopeier Tawniagan 2a: A HORDIRA On A tEAM caw PaETLETHY pie Yim sr meme Yq Wb ros O6kRcernO oes, save om MEEHECED ema You A Ym Yeon peyalans renee tr Saoi6h attics patie ro cher 4 moromoes am yd socom nus save and Counsor TO nner cin moO E AACN TO OREN FALESETCARTON To: APHORETERS.cectotar tee ony ons wD + 0302.32 - “ $MADL EMEW ‘THYS<26. YOUR RENEWAL NOTICE STATE BONRD OF MEDICINE a P.O. ROX 8428 DANTEL ALAN. : HARRISBURG, PA, 17205-8414 TAWRENCE Q8-GYM-ASSO D7 '§80. HEACOCK’ ROAD: LYARDLEY, PA 19067 FDpiON om Govan next To Sur farce me-uo amen tev AD noi ACO FIN BecNaATES GF one HM eM ada, “ie woo weicrtén au esmewLiozn; woo mer mie TaN REQUIRED 29CO"TOFPROPEHSEOUNL LARNILAE. THORAC, DA 1 9, DoD CAT. FIM EREMINCR. YALA FO R920, HEE UT. AUPERETON A ARVOOATICN UF weUR TOEHHT ==! pp breGicinnae Acraga TaN 3M aaoueR Sears, YoRiaTOR oR CUNTHY ataln BE AEFORHED TO THE SOkeD oH Ta BIGRMIAL EIB NORTGR WEED 8 DAZE OF eROW SIEFCETTZeH, WITCHTER To soGEER- 4p voo mwmain swear To GUEETIOUE 2, 2, 4, OR § BELOH, FLANGE MOvIDE COMPLETE BEMRLS foe You tat Rb, fas ANY DracsPLmURe ACIION BOY AKON AGADNOT YOUR LICRE IM AMOI BEATE, TERRETORE om” fina mere {vr 1208 CARE UGA, AWE YOU SHE-YOUR.DEA RIOTOTRATION BENTED, REVOKED OR RESTRICTED OM TAVE YOU MAD WON, pe 18 igi, Yo) RUZ eTILL ROGCLEAD TO AHONER THE QOEETIONS MECH von or emconrin. | (CE BY sono raanr a = pohettotat Yee oni uD > 0:3-0232-% ‘poss oF PharessfeaaE ann ‘OCCUPATIONAL AFFAIRS SHALL RWEW TRIS IS YOUR RENEWAL NOTICE STATE BOARD-OF MEDICINE P.O. BOK 9424 ‘ALAN SHALL HARRISBURG, PA, 7205-8414 ° LAWRENCE OB-GYN “ASSO, PA 680. HEACOCK ROAD YARDLEY, PA 19067 Youn connor Lichiae To PRACEICE MEEIEIOE s¥D soRaSRY iW PEMaYLWRTA WILE EEPIRE OH DECHNDAN 3], 199%. TO RONEN TuNCUOH ‘roman 21, 1096 punase CoMMLETE Ty QUEETIONS ARLOH NAD SUONET A CHECK. cm NOUR ORDER TuR KOO OF, f86.06,. DN RIVAL THE “COMOBREALEN OF PA:*, MECEED TOI LICENEE MAGN CH TOE FACNT GP YOUR PAYA. LATE VEOALTE TEE O”'§8.00 pan wo WILL mF CIARaRD YOR ENEWALE FeSTHARFRD APTI DACH’WER 32, 2994 A PROCESSING FE OF 420,00 WILL'BE CARED FOR ri cme Om HOREY ORDER TURD UHPAID PY YOUK DANK, REGARDLEEA OF THE REAR, IF. YOU HAVE A-CONMNE TH HAE A /OR. [poonaas, moreare 6, cwirE MEKY To Ts PA-pRIVTED WOE NM ABONABE AtOYE, . ea a iit orien x0 Ect 18 TER SORT, TEU AE REDTRE TREN EL RRCTER I Sess or tm mete momerous nave Caan tan mat Yo AE IMC ATA vere muoucticr hor 0) run votn (Ant Rew, You WOVE EXPERIENCS SIVFECULTIEN AB A RRIULY OF ALCONOL oR OMI eUDE suEN AM bIRGHoRLS Se? [TREATWDNT om GHBNIGAL SEPRAPRNEY Om AOLAE OH AAREETS YOR CIGNTERI-UHK-RELATED OFPRHORE, YOU MAY CONTACT TN BOREDD'S. LAPALIEN, horessiows, pRSoUN Poa COMPIDENTING GMTORRATION MD ARBEATINES AY 1-900-480-3028 (DEY DINCIRLAMARY ACTIGAE TARA IN ANOTINNG ATATE, TERRITOVCE Ok COAMTRY ANALL BE-AEPOITRY) TO THE boaKD OM TH U1 ONAL RIAL ORIG OL WIFI 10 DnB OF PORALCMEPOHZTION, WAICHEVER 18 doce, 2 yowiaern yeas r0-qumerzone 3. 1, 4. 08 iv, PLEARE WOVEN CoMMUETE HEASLA OF 8 1/2 x a8 © simeuuoe cos or Leon, vocok@erd, 17 ‘rat PoLowtno QUEsTioNS WORT RE peDNT AAO YOU MONT BIN DCH sees, - AL, bo WOU HOLD. LECRNEE TO PRAETHEN MEDICINE Su) SURORKY 24 ANY COMER SURDEDIOTIONY A YER, L267 RACE. {vee Yoo LART Ren, NCHA ACTION OREN HFEN nagintD YOUR SICRASE. IW MORI GEAR, AN) ORF Da ames veon ise tanavou, wae you wn cokezCHED, FOUND GOLLEY OF PLEATED OUILTY Gi WokO CONTINUA, MECEISED ERO: ‘ri WInIGU? VERDICT AB TO-AM FRLCRY O AIADBNERNOR, IWEAIG 9H DOO LAK VIOLATICN, Hf A BIRTE OH ADERAL COOK? 10, dv oe Nenana, wave YOU MAD PRACTICE PREVELAGEA OMED, WRVGHED Ow ARERICTND 38 A NOREDEAL om ten TY J Semenenin ance Yow Wey Apu, AVE YEU MAD YEU DEA RUOTATRARICN MENLEP|_ABVOHRD om aKimHioED on HAE, YEO WAH YoU ‘ovingk ontvrueces fenunanten By AW MEDICAL AESTETARCE StI Fo HUE? “av Wow ier ro mart voc Lromane mugcaD ct aNAeTIVES STATI, CHEE Ye REY TO. ANEVEK THE AOE GUERTIGNG A AKA BELO.aa0-0-89 CCommonvesth of Pevityhanla DEPARTMENT OF STATE urea of Proflondl and Occupations: Ati STATE BOARD OF MEDICAL EDUCATION AND LlCH/Unt ow. 2640 Panneylvanis 17320 SMALL Daniel = _ i ft 1. APPLICATION TO PRACTICE MEDICINE | hereby apply for icensute to practice medicine in the Corwmanwadth of Pentwyivanis, fr which an aitdevit {concerning age, chizenship; evidence of medical education evidence of gradupié traning, a cartes of maral ‘thal character, two recent photographs. and the proper fen are harewith inched we vequted by low. FEES. FLEX Examination $1500 Endorsement $1000 Limited License Professor $125 00 ‘tans mvs! be pad by CERTIFIED CHECK OR MONEY ORDER, made peysbe to the Commonsrdsith of Persian ME Application fees are-not refundable Address to which conse is to be sant —2'/ W-WAL 104 ib hl Vt ‘dees tor edmision to FLE — a cote th. III cet in Musonn, Now YORK. us cren Yes How secure Vise Statue: ExCNANG Vint nntnnees ntti Immigrant — —— Immigration Petition ‘ba you iténd to become a Siassiune of Applicant in Fi 2, MEDICAL EDUCATION Number of Date of vnaiutions “Manin anevion Unwenty lt lenny hati {cle he 450 beyond medical schoo! Med: tlie A Pewneyfvanra 9 - J Nt uaa DalyYou yin nnn ncn ei Pe oh a0, when? Be ‘ave (ot on on eon or ib oon omer sae of na Una Sain Mane? Rit Lcente(a)obtaineg Ua a wate) were ou hold media eensure sone te Hee ctr on nga rh ty W 20, give particulars Hava you aver bean convictad ofa elary inthe courts of this Commaniactth ox any othe sate teintoiy, oy county? no. a ‘Ware and to what capac fron ante 4. FOR CANDIDATES WHO WISH TO-BE ADMITTED TO THE E: . SEFORE COMPLETION OF ONE YEAR OF GRADUATE TRE {Cheteby carity that iio ordi vahing © ‘0 seat (NOTE: __ When you submit thia apilcation, detach the mimsograph blank, GRADUAT ‘After completion of your one your of graduate rlning, have It cerited bythe orsard directly to the State Bosrd Office kr Hetabury.rd tat the orgie ofthe preceding copy of etsie conte or corfcste Noy ain ued to Or of ~ - ~ ‘ane ery at the enconadphotoaroh as Sheets of _ael tthe Anenee or ceritcntn above caferred to has néver been sunpended or revoked, geo Ks»kcren by endorsement i requred to havea inte wth 8 membarof he Perneivan Ste See of Medical Faveeion ved Ucensute or raprasenttive of the Boerd. 2 Raia Renee6: APHIDAVI OF Td PRESIDENT OR SECRETARY OF A COUITY MEDICAL SOCIETY ~ State of of the. Metical Society ; tat he Howe the appicon to tro ed vg re i it ft edo ere eared te Secret pit Fer — 1 Yana Rae Tesoro Raat Si 7. CERTIFICATE OF MORAL CHARACTER 8 Tobe sxred by two phynclna with umecticied Hewnsure In good sand n United States is criti tat wi haven gentwunid is Davie Sal. Bie. Aa and Ly, aac tat Deane Sil sat ot in Interiparate use of slcohot ornare drugs; that we now Damiel Saal. tote ot ood moiaicharn or amt arty recommend DAEA $a lL to be worthy of heansute to preccn madione w the Comne “of : Peevisyvacia. pursuant to fam, Pawel Soa applicant! who beng daly sworn says, that ‘a the pereon relored to m the above appheaton for Ueanss 10 practice meric & ‘Pennayivana, that the statements on page one ate in HL $a tf te in vey sapat that 0 “BAAD cist « i lees of any state rafered io therein Maen Ds soritbest ree349089 CERTIFICATE OF MEDICAL EDUCATION ‘Commdnvieaith of, Penhaylvania State'Board of Medical Bauention Department of State. and Licensure, s Bureau ‘of Professional and PO. Bon 2649S ‘Occupational \Aéfairs HareLabitgs Pépneylvanse 1710 Pp Be Completed cant: ‘YWubait cosploted Certificate with Application) ane of apphicane aban Signature of Applicant as Bame of Medical School (: a : ig Address of Medical school [i{1) ry 183 sag Beginning pate __{ raduation oate 12. fe fom cincaiss wae pylon Gers coaietad STUN Eo topLicant, So aot aba to bode Thereby certify that | UAyset ALAN. 4 kt (1) ae ereanted fron hunt lnst ction ots nts ts) Fee eee ee eee eae ee veka of sat ee Than Dnt Shee nats, eer ne eg cay et 0) stmnatnts eh sapeaieyrinces fo ete (3 ator eet te hs ot otc, (lace seat Sdor sigfiatire) Seal must appear on a part of the photograph. ‘Tyo photographs are required if applying for Licensure by examination, One photograph is required if applying for Lleensure by endorsenont arin Fors on Reverse)“Tao £ graduation. dovissnot, cout Medion! tavcation and tlat a “saTiOWAl. BOARO OF MEDICAL EXAMINERS # ENDORSEMENT OF CERTIFICATION a imag " uwetEO states OF AMERICA Daniel Ae Seattle Meds ving sighed the ean a6 hag sce abd te ‘vont net fe Nations! Bord Mikal Baas. ‘ute Co: WILLIAM OAESCHNERY: Je ‘vou SEAL ining 07/01/83 Contticate # 267608 ‘stm of he Damas Cai apie wig Pode risen sah sve whe waded om) PENNSYLLVANTA fs may “igag “eodonbuheneh {i} onions read or earUeton by. ha Navn ‘his physician ison whieh hihrcertiaton bist ate ot Hollows: ant otona ‘ten il age So to ays Buhetry Patbloey Uist, menvoiony Pcacctogy wd Motrl Medi nowt scenes, TOTAL TEST tttmum Posing Sore 00/181 Pat I pase 2 “etna madicne Sn she neaeaT eats Sarg ae! the suglea! speelaties ‘Obstettis ar! Gynmcolony Publi Heth ard Preventive Mating Petits Papehiairy ‘TOTAL TEST (Minium Pashing Seove 200/061 PART I pad 93783 ‘R Genial Test of Gina Competericn TOTAL TEST (Minium Pasig Scote 290/781 GENERAL AVERAGE (Pats, 1 at Ht Seat Score) “For thow indivkluals who hove not yel sUslttoiy cOmpeled ane Ault yea! ft aig Shown on the fein le tho date wiveh hat heen ceri by th physics retary prog weet 2a date which thi oqutement for euligon by wh ant De it ales mh ean be sword, Sect tor 09/47/03 Daento be srthy of the meta a fetleang type Uf prewri Le EATEGORICAL* _ cA GbHIEAL SPECIALTY, PONTE Wei Wi Le Cottier GonCotrcinasIth of Pennsylvania ‘Depreient of State Bureau of Professional and ‘Occupational Atfairs vel omvell thine’ of ‘Applicant,., Deis : @ his protogroph is a true Likeneis of ‘the applicant. ‘ Le fist all states, teirftories, and comnbriés JPWHen Jol License to practice madicine and suryery (active or snactlva) 2.° Ace you, or have you over bean, addicted to the Intenjrrate use of alectnl or fubitusl use of narcotics or other babit-forming drugn?, 2 3. lave you wor Leen convicted of a etine {exchisive of parking esd traffic violatle fin the courts of this-Camoreealth or any other state, territory, of Guuitty?, 4y tive you ever gousconad a Laense bo pravtice nedielse atd surgery Or other fessional license ‘ius tae campo |, revpked Or subjected to clive diszipl inary Conditions? no, _ : 5. Have your provider privileges ever been revtrlectedl by frog Bnforedent dei Medicare or any others? Ng " have anvssred yes to 1, 2, 3,4, oF S please provide details on an atteched IE, t, i. i, 4 Plosse’ explain your relationship with the Wo physicians whe ot pleterl Seetion 7 Fe en ee ctor of your iiecous aplication. tee on aidktiaal sheet. Stal physicians Medreal eetlege ob Affidavit State of bow ven Gone at County of J2 fintarele Ghim {applicant} being duly ease acvonding 06 las, Rests itt abe serait completing thie fore and tak Ua atatereats SHS and cmpleta to the best of his/her lnwdlaige ard belief. Subscribpl and sworn to befece me this 27 day Off igleaba AE Chk i Rotary