Organization
OVERLAKE COLON & RECTAL CLINIC, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MITRA EHSAN MD (OWNER)
(206) 669-7639
Entity
Organization
Contact information
Practice address
1135 116TH AVE NE, SUITE 190, BELLEVUE, WA 98004-4623
(425) 646-7400
(425) 646-7449
Mailing address
PO BOX 597, BELLEVUE, WA 98009-0597
(206) 669-7639
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
MD00039612
WA
208C00000X
Colon & Rectal Surgery Physician
Primary
MD00039612
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0159746
L&I
WA
05
—
1115864
—
WA
01
—
1135EH
REGENCE
WA
01
—
2185705
UNITED HEALTH CARE
WA
01
—
5810380
AETNA
WA
Enumeration date
05/07/2008
Last updated
09/04/2019
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