Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202167441
Date :
28/12/2021
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 2nd Floor,
Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
Sub: Dr (Smt/Shri)
PRABHUDESAI PRALHAD PRABHAKAR
Registration No:
54949
Registration Date :
09/09/1985
Valid upto Date :
28/02/2027
Sir,
I the undersigned applicant, request yoy that my name may be continued on the Register of Medical Practitioners maintained by the Maharashtra Medical Council as per 23 (a)/23 (c) of MMC Act 1965 and amendment 2003. My particulars are as Follows :
Name of Applicant
:
Mr.
PRABHUDESAI
PRALHAD
PRABHAKAR
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
4044TH FLOOR, PLOT -A, VASANT GALAXY, BANGAR NAGAR, GOREGAON(W), MUMBAI
City
:
MUMBAI (SUBURBAN)
District
:
MUMBAI (SUBURBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400090
Date of birth
:
10/12/1961
Tel No (Res)
:
Clinic No
:
Mobile No
:
9821053689
Email Id
:
aumclinic@hotmail.com
Total Obtained Credits Points
:
266
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
TNMC MUMBAI
BOMBAY UNIVERSITY
1985
2.
M.D.(Tuberculosis)
TNMC MUMBAI
BOMBAY UNIVERSITY
1988
0018/2012
04/01/2012
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202136298284918
Receipt Date
:
29/12/2021
I have uploaded following documents:
1.
Latest Passport size Photograph
DECLARATION (Registered Medical Practitioner)
I shall abide by the Code of medical Ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
Date :
28/12/2021
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.