Application for
Renewal Of Registration
with the
Maharashtra Medical Council, Mumbai
Application No :
MMC202223117
Date :
21/01/2022
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)
NADKARNI SUSHIL PANDURANG
Registration No:
2000093290
Registration Date :
22/09/2000
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.
NADKARNI
SUSHIL
PANDURANG
Name of Father
:
Mr.
Name of Mother
:
Mrs.
In Case of Married Women
Maiden Name
:
-
RESEDENTIAL ADDRESS
:
12/3 ,MAHIM , JOLLY-COTTAGECO-OP HSG.SOC , 494-D, BHAGOJI KEER MARG , MAHIM , MUMBAI
City
:
MUMBAI (URBAN)
District
:
MUMBAI (URBAN)
State
:
MAHARASHTRA
Country
:
INDIA
Pincode
:
400016
Date of birth
:
03/09/1940
Tel No (Res)
:
022 24453597
Clinic No
:
Mobile No
:
9819803940
Email Id
:
snadkarniz@hotmail.com
Total Obtained Credits Points
:
0
Remaining Credits Points
:
0
Qualification Details
Details of Qualification
Name of College
University
Passing Year
Certificate No
Certificate Date
1.
M.B.B.S.
M.G.M INDORE
VIKRAM UNIVERSITY, UJJAIN
1963
2.
M.S.(Genl. Surg.)
TNMC MUMBAI
MUMBAI UNIVERSITY
1969
15191
22/09/2000
Pariticulars Of Payment
Payment Mode
:
Online Payment
Receipt No
:
202202162728995
Receipt Date
:
24/01/2022
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 :
21/01/2022
Applicant signature
NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.