Provider Demographics
NPI:1124451604
Name:SISSOKO, BAKARY
Entity type:Individual
Prefix:MR
First Name:BAKARY
Middle Name:
Last Name:SISSOKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 CONTINENTAL CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1406
Mailing Address - Country:US
Mailing Address - Phone:317-529-6225
Mailing Address - Fax:317-245-6215
Practice Address - Street 1:4007 CONTINENTAL CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1406
Practice Address - Country:US
Practice Address - Phone:317-529-6225
Practice Address - Fax:317-245-6215
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN265127343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201158900AMedicaid