Healthcare Provider Details

I. General information

NPI: 1568044113
Provider Name (Legal Business Name): RAVEN GWENDOLYN DIACOU MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 ST LUKES BLVD STE 104
EASTON PA
18045-5665
US

IV. Provider business mailing address

2200 ST LUKES BLVD STE 104
EASTON PA
18045-5665
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-6643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD490075
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: