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:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 19TH AVE S APT 1618TH
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2717
Mailing Address - Country:US
Mailing Address - Phone:843-442-9845
Mailing Address - Fax:
Practice Address - Street 1:1002 N CHURCH ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1447
Practice Address - Country:US
Practice Address - Phone:336-890-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN# 19647208600000X
NC2024-03284208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN158504375OtherDRIVERS LICENSE