Basic Information
| Provider Information | |||||||||
| NPI: | 1255403085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLOMON | ||||||||
| FirstName: | OLIVER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099719334 | ||||||||
| FaxNumber: | 9099719654 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 WEST ROUTE 66 | ||||||||
| Address2: | SUITE 326 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269638588 | ||||||||
| FaxNumber: | 6269688578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20A7503 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20A7503 | 01 | CA | MEDICARE | OTHER | 00AX75030 | 05 | CA | MEDICAID |