Basic Information
| Provider Information | |||||||||
| NPI: | 1376543280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLOMON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/14/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G6020 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | C5453 | AR | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 107752001 | 05 | AR | MEDICAID | 100569601 | 05 | TX | MEDICAID |