MEDICARE: DUSTIN JOHN FANCIULLO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	14267138-1205	UT
2	2086S0129X	Vascular Surgery Physician	14267138-1205	UT

General Provider Information

NPI Number	:	1013164052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN JOHN FANCIULLO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 281490
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-1490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 E 3900 S STE 3100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1290
Country	:	US
Telephone Number	:	801-262-2806
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2008
Last Update Date	:	03/02/2026

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