Provider Demographics
NPI:1104817287
Name:BANCROFT, LAURA WASYLENKO (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:WASYLENKO
Last Name:BANCROFT
Suffix:
Gender:F
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:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1508
Mailing Address - Country:US
Mailing Address - Phone:941-488-7781
Mailing Address - Fax:941-486-8991
Practice Address - Street 1:601 E. ROLLINS STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-303-8178
Practice Address - Fax:407-303-9702
Is Sole Proprietor?:No
Enumeration Date:2005-10-29
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME654402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268756900Medicaid
FL28439OtherBLUECROSS/BLUESHIELD
FL300055808OtherRAILROAD MEDICARE
FL268756900Medicaid
FL300055808OtherRAILROAD MEDICARE
FLG21133Medicare UPIN