SuperPumpedPeptides | Boutique Peptide Therapy for Everyone

Physician Application

Apply to join our telehealth platform as a licensed medical provider. All credentials will be verified before activation.

Personal Information

First Name *

Last Name *

Email *

Password *

Phone

Medical Credentials

NPI Number *

DEA Number

Medical School *

Graduation Year *

Specialty *

Board Certified

State Medical Licenses *

License 1

State

License Number

Type

Expiry Date

Malpractice Insurance

Insurance Carrier *

Policy Number *

Policy Expiry Date *

CV / Credentials Upload

Upload CV (PDF, max 10MB)

By submitting, you agree to our credentialing process. Your information will be verified by our medical administration team.