Provider Demographics
NPI:1437182516
Name:FANCIULLO, JOSEPH J (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:FANCIULLO
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:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:
Practice Address - Street 1:6100 S LOUISE AVE STE 1130
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-6021
Practice Address - Country:US
Practice Address - Phone:605-504-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4251207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6630074Medicaid
SDP00757173OtherRR MEDICARE
SD660003929OtherRAILROAD MEDICARE
SD6630073Medicaid
SD6630074Medicaid
G48496Medicare UPIN
SDS40651Medicare PIN