Provider Demographics
NPI:1679035612
Name:SOLOMON, DUSTIN P (MS RD LDN)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:P
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933-5032
Mailing Address - Country:US
Mailing Address - Phone:618-364-5672
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-651-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006736133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal