Provider Demographics
NPI:1578625158
Name:UNZICKER-FASSERO, TERA LYN (OD)
Entity Type:Individual
Prefix:DR
First Name:TERA
Middle Name:LYN
Last Name:UNZICKER-FASSERO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 WESTBRANCH HWY
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-6605
Mailing Address - Country:US
Mailing Address - Phone:570-768-4970
Mailing Address - Fax:
Practice Address - Street 1:23 S ARCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-1124
Practice Address - Country:US
Practice Address - Phone:570-768-4970
Practice Address - Fax:570-768-4902
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
50072024OtherCAPITAL BLUE
822469OtherFIRST PRIORITY
1424800OtherBLUE SHIELD
97422OtherGEISINGER
1424800OtherBLUE SHIELD
084378E3FMedicare PIN