Healthcare Provider Details

I. General information

NPI: 1013164052
Provider Name (Legal Business Name): DUSTIN JOHN FANCIULLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 E 3900 S STE 3100
SALT LAKE CITY UT
84124-1290
US

IV. Provider business mailing address

PO BOX 281490
ATLANTA GA
30384-1490
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-2806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14267138-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number14267138-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: