Healthcare Provider Details

I. General information

NPI: 1669679809
Provider Name (Legal Business Name): MOUSSA SISSOKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 MACCORKLE AVENUE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

3415 MACCORKLE SEAVE
CHARLESTON WV
25304-1334
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8380
  • Fax: 304-388-8395
Mailing address:
  • Phone: 304-388-8380
  • Fax: 304-388-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2024-02971
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number24149
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number24149
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: