Provider Demographics
NPI:1639254162
Name:SOPOV, ELISE CHASSEN
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:CHASSEN
Last Name:SOPOV
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELISE
Other - Middle Name:MELANIE
Other - Last Name:CHASSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:71 BERGEN DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-1341
Mailing Address - Country:US
Mailing Address - Phone:973-200-0896
Mailing Address - Fax:844-436-5129
Practice Address - Street 1:1376 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1011
Practice Address - Country:US
Practice Address - Phone:973-200-0896
Practice Address - Fax:844-436-5129
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ524390Medicare PIN