Provider Demographics
NPI:1770005357
Name:PARK, SOLOMON (MD MPH)
Entity Type:Individual
Prefix:
First Name:SOLOMON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7353
Mailing Address - Fax:
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-286-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021021838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program