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General NPI Number Information
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NPI Number | 1063688273
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Entity Type | Organization
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Legal Business Name | OVERLAKE COLON & RECTAL CLINIC, PLLC
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 09/04/2019
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Provider Practice Location Address
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Address Line | 1135 116TH AVE NE SUITE 190
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City | BELLEVUE
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State | WA
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Zip | 98004-4623
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Country | US
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Telephone | 425-646-7400
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Fax | 425-646-7449
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Provider Business Mailing Address
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Address Line | PO BOX 597
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City | BELLEVUE
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State | WA
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Zip | 98009-0597
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Country | US
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Telephone | 206-669-7639
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MITRA EHSAN
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Credential | MD
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Telephone | 206-669-7639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD00039612
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | MD00039612
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License Number State | WA
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