Provider Demographics
NPI:1033215405
Name:SOLOMON DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:SOLOMON DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-974-3659
Mailing Address - Street 1:11361 N 99TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-5470
Mailing Address - Country:US
Mailing Address - Phone:623-974-3659
Mailing Address - Fax:
Practice Address - Street 1:11361 N 99TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5470
Practice Address - Country:US
Practice Address - Phone:623-974-3659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11510174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0853180OtherBC PROVIDER ID
AZ99S010800001OtherMEDISUN ID
AZ2173735OtherAETNA ID
AZ118412Medicare PIN
AZAZ0853180OtherBC PROVIDER ID