- All name changes must be reported to the appropriate board.
New Jersey State Board of Medical Examiners at PO Box 183 Trenton NJ 08625 or
New Jersey State Board of Optometrists at PO Box 45012 Newark NJ 07101.
Mailing Address (required)
- This address is for Profile contact purposes only and will not be made available to the public.
To update your mailing address for licensure purposes contact either
the New Jersey State Board of Medical Examiners at PO Box 183 Trenton NJ 08625 or
the New Jersey State Board of Optometrists at PO Box 45012 Newark NJ 07101
- Review the preprinted data.
- If data is correct, click on Accurate as Displayed.
- If data is incorrect, enter the correct information, click on Change as noted.
Make any necessary changes. (Not all information can be changed.)
- If you are reporting an address that is located within the United States, please do not enter
any information into Line 4 as this will be used to store the City, State and Zip Code
information. Enter the City, State and Zip Code in the individual fields provided.
- If you are reporting an address that is not located within the United States, please enter
the complete address information in Lines 1 through 4. Do not enter any information in the
City, State or Zip Code fields.
Contact Information (optional)
This information is for contact purposes only and will not be made available to the public.
Enter the following information (any format will be accepted):
- Phone Number: The daytime phone number at which you can be reached in the event that a question
arises regarding information that you have submitted in your profile.
- Fax Number
- E-Mail address
NJ License to Practice(required)
- Verify the preprinted information. The license number and year conferred information cannot
be changed. If this information is in error or blank, contact either the New Jersey State Board
of Medical Examiners at PO Box 183 Trenton NJ 08625 or the New Jersey State Board of Optometrists at PO Box 45012 Newark NJ 07101.
- If initially licensed to practice outside of the State of New Jersey, enter the year
you were first licensed.
Specialty (required for Medical Doctors/Podiatrists only)
- Review the pre-printed data.
- If the specialty displayed is correct; click on Accurate as Displayed.
- If you would like to change the specialty that is pre-printed or if a specialty is not
pre-printed; click on Change as Noted and click on Select to bring you to the Select
- The Select page displays the list of specialties. You must select from this list, you cannot
type in a specialty.
- Locate your Specialty then click in the button to the left of the Specialty that you want to
- Click on 'Return to Practitioner Information Page' button.
- Click the 'Clear' button if you wish to delete the displayed Specialty and begin the search
When finished, click one of the buttons at the bottom of the screen:
- Save & go to previous page
- Save & stop for now
- Save & go to next page