Healthcare Provider Details

I. General information

NPI: 1154857514
Provider Name (Legal Business Name): DR. MAAZ AHMED GHOURI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST # OR2029
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8623
  • Fax:
Mailing address:
  • Phone: 706-791-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2023024861
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number47710
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number2023024861
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number102316
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number47401
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number47710
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: