Provider Demographics
NPI:1760481626
Name:SOLOMON, GLEN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:DAVID
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5200
Mailing Address - Fax:414-259-0469
Practice Address - Street 1:1222 S PATTERSON BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2684
Practice Address - Country:US
Practice Address - Phone:937-223-5350
Practice Address - Fax:937-224-3112
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066707207R00000X
WI862922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0708569Medicaid
OHSO0622593Medicare PIN
202129Medicare ID - Type Unspecified
OH0708569Medicaid