Provider Demographics
NPI:1013164052
Name:FANCIULLO, DUSTIN JOHN (MD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JOHN
Last Name:FANCIULLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3036
Mailing Address - Country:US
Mailing Address - Phone:585-922-5550
Mailing Address - Fax:585-922-0450
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3036
Practice Address - Country:US
Practice Address - Phone:585-922-5550
Practice Address - Fax:585-922-0450
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252553-12086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400050228Medicare PIN