Healthcare Provider Details

I. General information

NPI: 1679035612
Provider Name (Legal Business Name): DUSTIN P SOLOMON MS RD LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

307 FRONT ST
ENERGY IL
62933-5032
US

V. Phone/Fax

Practice location:
  • Phone: 314-651-4100
  • Fax:
Mailing address:
  • Phone: 618-364-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number164006736
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: