Provider Demographics
NPI:1669679809
Name:SISSOKO, MOUSSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUSSA
Middle Name:
Last Name:SISSOKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 MACCORKLE SEAVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1334
Mailing Address - Country:US
Mailing Address - Phone:304-388-8380
Mailing Address - Fax:304-388-8395
Practice Address - Street 1:3415 MACCORKLE AVENUE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-8380
Practice Address - Fax:304-388-8395
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24149207RG0300X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00867219Medicare PIN
SI4295571Medicare PIN