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DINAS KESEHATAN PROVINSI JAWA TIMUR

UPT RS PARU SURABAYA


KOMITE MEDIK
JL. Karang Tembok no. 39 Surabaya. Telp.(031) 371 38 36 Fax (031) 372 88 90 Surabaya

o Credentialing
o Re-Credensialing
Tanggal.................................

IDENTITAS
Nama Lengkap : .....................................................................................................................
Gelar Profesi : .....................................................................................................................
Alamat : .....................................................................................................................
No, Telepon : .....................................................................................................................
Tempat/Tanggal lahir : .....................................................................................................................
Jenis Kelamin : Pria / Wanita
No. KTP : .....................................................................................................................
Anggota IDI Cabang : .....................................................................................................................
No Anggota : .....................................................................................................................

PENDIDIKAN
PENDIDIKAN DOKTER UMUM
Universitas : ....................................................................................................................
Alamat : ....................................................................................................................
Gelar : .................................................. Tahun masuk : .........................................
Bulan/Tahun Lulus : .....................................................................................................................
PENDIDIKAN DOKTER SPESIALIS
Universitas : ....................................................................................................................
Alamat : ....................................................................................................................
Spesialis : .................................................... Tahun masuk : ......................................
Bulan/Tahun Lulus : ....................................................................................................................

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