Healthcare Provider Details

I. General information

NPI: 1649219395
Provider Name (Legal Business Name): TIMOTHY DAVID BANCROFT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 VALLEY CENTRE DR MAIL DROP S99
SAN DIEGO CA
92130-3318
US

IV. Provider business mailing address

FILE# 54433
LOS ANGELES CA
90074-4433
US

V. Phone/Fax

Practice location:
  • Phone: 858-764-3000
  • Fax:
Mailing address:
  • Phone: 858-764-3000
  • Fax: 858-784-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1879101205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: