Provider Demographics
NPI:1174970198
Name:MONTORFANO, LISANDRO MIGUEL (MD)
Entity type:Individual
Prefix:DR
First Name:LISANDRO
Middle Name:MIGUEL
Last Name:MONTORFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16280 LA COSTA DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1422
Mailing Address - Country:US
Mailing Address - Phone:843-442-9845
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3609
Practice Address - Country:US
Practice Address - Phone:954-659-5473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN# 19647208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM536533890180OtherDRIVERS LICENSE