Provider Demographics
NPI:1649219395
Name:BANCROFT, TIMOTHY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
Last Name:BANCROFT
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:FILE# 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4433
Mailing Address - Country:US
Mailing Address - Phone:858-764-3000
Mailing Address - Fax:858-784-5960
Practice Address - Street 1:3811 VALLEY CENTRE DR
Practice Address - Street 2:MAIL DROP S99
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3318
Practice Address - Country:US
Practice Address - Phone:858-764-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1879101205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057090Medicaid
UTF79255Medicare UPIN
UT000064050Medicare PIN