Provider Demographics
NPI:1851419857
Name:PINGUL, MIA FARIDA MEDIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIA FARIDA
Middle Name:MEDIANA
Last Name:PINGUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 HAMAKER CT
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2207
Mailing Address - Country:US
Mailing Address - Phone:703-876-2788
Mailing Address - Fax:
Practice Address - Street 1:3023 HAMAKER CT
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2207
Practice Address - Country:US
Practice Address - Phone:703-876-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012585082080P0205X
NC2011-014082080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLL1577OtherLICENSE
NC165GNOtherBCBSNC
NVASO2532199116OtherDEA LICENSE
NVWQBHVMedicare ID - Type UnspecifiedGROUP MEDICARE
NC5918543Medicaid
NV100500484Medicaid
NCNC1698AMedicare PIN