Healthcare Provider Details

I. General information

NPI: 1851419857
Provider Name (Legal Business Name): MIA FARIDA MEDIANA PINGUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

IV. Provider business mailing address

8401 MAYLAND DR # 4782
RICHMOND VA
23294-4648
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 703-539-2172
  • Fax: 312-900-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number0101258508
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number15279
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: