Basic Information
| Provider Information | |||||||||
| NPI: | 1649219395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANCROFT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE# 54433 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587643000 | ||||||||
| FaxNumber: | 8587845960 | ||||||||
| Practice Location | |||||||||
| Address1: | 3811 VALLEY CENTRE DR | ||||||||
| Address2: | MAIL DROP S99 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921303318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587643000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 1879101205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 942854057090 | 05 | UT | MEDICAID |