Provider Demographics
NPI:1073543559
Name:BANCROFT, GREGORY (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BANCROFT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 LANCASTER AVE
Mailing Address - Street 2:A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-1712
Mailing Address - Country:US
Mailing Address - Phone:215-222-2225
Mailing Address - Fax:215-222-3070
Practice Address - Street 1:4014 LANCASTER AVE
Practice Address - Street 2:A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1712
Practice Address - Country:US
Practice Address - Phone:215-222-2225
Practice Address - Fax:215-222-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-001795-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005005270002Medicaid
PABA066714Medicare ID - Type Unspecified