Provider Demographics
NPI:1336209063
Name:MONTALVO BURKE, LISANDRO
Entity Type:Individual
Prefix:
First Name:LISANDRO
Middle Name:
Last Name:MONTALVO BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:PMB 6017
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-6017
Mailing Address - Country:US
Mailing Address - Phone:787-886-3254
Mailing Address - Fax:787-957-1555
Practice Address - Street 1:URB VILLAS DE LOIZA
Practice Address - Street 2:CALLE 1 B 1 ALTOS FARMACIA MEDINA 2
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-886-3254
Practice Address - Fax:787-957-1555
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13908207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0023179Medicare ID - Type Unspecified