Provider Demographics
NPI:1710327754
Name:MORGUNOFF, ANDRE
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:
Last Name:MORGUNOFF
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 1:18 PRICE LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7417
Mailing Address - Country:US
Mailing Address - Phone:609-335-1351
Mailing Address - Fax:
Practice Address - Street 1:18 PRICE LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7417
Practice Address - Country:US
Practice Address - Phone:609-335-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28616097Medicaid