Healthcare Provider Details

I. General information

NPI: 1336053107
Provider Name (Legal Business Name): CONSTANTINE GLEBOFF RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 SANFORD AVE
CLINTON NY
13323-1342
US

IV. Provider business mailing address

166 SANFORD AVE
CLINTON NY
13323-1342
US

V. Phone/Fax

Practice location:
  • Phone: 917-574-8648
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number526749
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: