INDIVIDUAL PROVIDER PROFILE PAGE¶

Prefix:¶

Providing the provider’s Name Prefix under both Provider Name Information as well as Other Name (if applicable) is optional.

• Dr.
• Miss
• Mr.
• Mrs.
• Ms.
• Prof.

First:¶

You must provide the provider’s First Name is Required. The First Name associated with an Other Name is only required if a Type of Other Name is selected.

Middle:¶

Providing the provider’s Middle Name under both Provider Name Information as well as Other Name (if applicable) is optional.

Last:¶

You must provide the provider’s Last Name is Required. The Last Name associated with an Other Name is only required if a Type of Other Name is selected.

Suffix:¶

Providing the provider’s Name Suffix under both Provider Name Information as well as Other Name (if applicable) is optional.

• I
• II
• III
• IV
• V
• VI
• VII
• VIII
• IX
• X
• Jr.
• Sr.

Credential(s): (M.D, D.O, etc.)¶

Providing the provider’s Credentials is optional.

Type of Other Name:¶

Providing an Other Name is optional. However, if you provide one, you must identify what type of Other Name you are providing. Select the Type of Other Name from the dropdown list. Your options are:

• Former Name
• Professional Name
• Other Name

Date of Birth:¶

• Date of birth (DOB) is a required field. A Lock icon is provided to indicate that it will NOT be publicly available.
• You will receive a warning message if the Provider is more than 75 years of age. The warning message will not prohibit you from submitting the NPI application.
• Providers must be at least 18 years of age to obtain an NPI. You will receive an error message and will not be able to submit the NPI application if the provider is under 18.
• Providers who already have NPIs, the DOB will not be displayed on this page for privacy reasons. If you want to correct your DOB, please contact the NPI Enumerator at 1-800-465-3203.

Social Security Number (SSN) Field:¶

• Social Security Number (SSN) is a required field. A Lock Icon is provided to indicate that it will NOT be publicly available.
• If this is a new application, furnish your Social Security Number (SSN) for purposes of unique identification. For providers who already have NPIs, SSN will not be displayed on this page for privacy reasons.
• If you want to correct your SSN, please contact the NPI Enumerators at 1-800-465-3203.

State of Birth (If born in the U.S.) and Country of Birth fields:¶

• A provider’s State of Birth must be provided if the Country of Birth selected is U.S. (United States). You can select the state of birth from the drop down box list.
• Country of Birth is a required field. You can select the country from the drop down box list.

Gender:¶

The gender of the provider is required. Indicate the gender by selecting the appropriate Radio Button, ‘Male’, ‘Female’, ‘Unspecified or Another Gender Identity’, or ‘Undisclosed’.

Is the Provider a Sole Proprietor?:¶

You are required to indicate whether or not the Provider is a Sole Proprietor, by selecting one of the two Radio Buttons, Yes or No.

• A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.
• In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.
• There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.
• In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).
• As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)

A sole proprietorship may or may not have employees. * Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor’s SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship’s EIN. * Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).

Other Optional Information:¶

Ethnicity, Race, and Language(s) spoken are not mandatory fields. Ethnicity: You can identify the provider’s Ethnicity, by selecting one of the two Radio Buttons:

• Not of Hispanic, Latino/a or Spanish Origin
• Hispanic, Latino/a or Spanish Origin

Race: You can identify the provider’s Race by selecting one or more of the following:

• White
• Black or African American
• American Indian or Alaska Native
• Asian
• Native Hawaiian or other Pacific Islander

If you select “Asian” you will be asked to further refine your answer by selecting one or more of the following:

• Asian Indian
• Chinese
• Filipino
• Japanese
• Korean
• Vietnamese
• Other Asian

If you select “Native Hawaiian or Other Pacific Islander”, you will be asked to further refine your answer by selecting one or more of the following:

• Native Hawaiian
• Guamanian or Chamorro
• Samoan
• Other Pacific Islander

Primary Language Spoken: Indicate the primary language spoken by the provider, by selecting one listed language from the provided scroll window. Secondary Languages Spoken: Indicate the secondary languages spoken by the provider, by selecting one or more listed language/s from the provided scroll window.