Healthcare Provider Details

I. General information

NPI: 1063688273
Provider Name (Legal Business Name): OVERLAKE COLON & RECTAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE SUITE 190
BELLEVUE WA
98004-4623
US

IV. Provider business mailing address

PO BOX 597
BELLEVUE WA
98009-0597
US

V. Phone/Fax

Practice location:
  • Phone: 425-646-7400
  • Fax: 425-646-7449
Mailing address:
  • Phone: 206-669-7639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00039612
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD00039612
License Number StateWA

VIII. Authorized Official

Name: MITRA EHSAN
Title or Position: OWNER
Credential: MD
Phone: 206-669-7639