Healthcare Provider Details

I. General information

NPI: 1699014464
Provider Name (Legal Business Name): DERIC H NYE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W EUGIE AVE STE 100
GLENDALE AZ
85304-1256
US

IV. Provider business mailing address

5601 W EUGIE AVE STE 100
GLENDALE AZ
85304-1256
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-4510
  • Fax: 602-865-6100
Mailing address:
  • Phone: 602-865-4510
  • Fax: 602-865-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number20A17398
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number009320
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: